Article Summaries

classification and assessment of abnormal behavior CHAPTER 4 81

Clinical scientists hope that similar progress will be made in the field of psychopathology (Murphy, 2006). Mental disorders are currently classified on the basis of their descriptive features or symptoms because specific causal mechanisms have not yet been discovered. While we may eventually develop a more so- phisticated, theoretical understanding of certain disorders, this does not necessarily mean we will ever know the precise causes of disorders or that it will be possible to develop a classification sys- tem based entirely on causal explanations (Kendler et al., 2011). In fact, the most likely explanations for mental disorders involve complex interactions of psychological, biological, and social sys- tems (see Chapter 2).

Classifying Abnormal Behavior We need a classification system for abnormal behavior for two primary reasons. First, a classification system is useful to clini- cians, who must match their clients’ problems with the form of intervention that is most likely to be effective. Second, a classi- fication system must be used in the search for new knowledge. The history of medicine is filled with examples of problems that were recognized long before they could be treated successfully. The classification of a specific set of symptoms has often laid the foundation for research that eventually identified a cure or a way of preventing the disorder.

Modern classification systems in psychiatry were intro- duced shortly after World War II. During the 1950s and 1960s, psychiatric classification was widely criticized. One major criti- cism focused on the lack of consistency in diagnostic decisions (Nathan & Langenbucher, 2003). Independent clinicians fre- quently disagreed with one another about the use of diagnos- tic categories. Objections were also raised from philosophical, sociological, and political points of view. For example, some critics charged that diagnostic categories in psychiatry would be more appropriately viewed as “problems in living” than as medical disorders (Szasz, 1963). Others were concerned about the negative impact of using diagnostic labels. In other words, once a psychiatric diagnosis is assigned, the person so labeled might experience discrimination of various kinds and also find it more difficult to establish and maintain relationships with other people (see Labels and Stigma on page 82). These are all serious problems that continue to be the topic of important, ongoing discussions involving mental health professionals as well as patients and their families. Debates regarding these is- sues did fuel important improvements in the diagnosis of men- tal disorders, including emphasis on the use of detailed criteria sets for each disorder.

Currently, two diagnostic systems for mental disorders are widely recognized. One—the Diagnostic and Statistical Man- ual (DSM)—is published by the American Psychiatric Asso- ciation. The other—the International Classification of Diseases (ICD)—is published by the World Health Organization. Both systems were first developed shortly after World War II, and

both have been revised several times. Because the American diagnostic manual is now in its fifth edition, it is called DSM-5. The World Health Organization’s manual is in its tenth edition and is therefore known as ICD-10. The two manuals are quite similar in most respects. Most of the categories listed in the manuals are identical, and the criteria for specific disorders are usually similar.

The DSM-5 System More than 200 specific diagnostic categories are described in DSM-5. These are arranged under 22 primary headings. A com- plete list appears inside the back cover of this book. Disorders that present similar kinds of symptoms are grouped together. For example, conditions that include a prominent display of anxiety are listed under “Anxiety Disorders,” and conditions that involve a depressed mood are listed under “Depressive Disorders.”

The manual lists specific criteria for each diagnostic cat- egory. We can illustrate the ways in which these criteria are used by examining the diagnostic decisions that would be considered in Michael’s case. The criteria for obsessive–compulsive disorder (OCD) are listed in DSM-5: Criteria for Obsessive-Compulsive Disorder (see page 83). Michael would meet all of the crite- ria in “A” for both obsessions and compulsions. His repetitive hand-washing rituals were performed in response to obsessive thoughts regarding contamination. Consistent with criterion “B,” Michael’s compulsive behaviors were time consuming and inter- fered with his family’s routine. His relationships with friends were severely limited because he refused to invite them to his house, fearing that they would spread contamination.

For various types of disorders, the duration of the problem is considered as well as the clinical picture. For example, criterion “B” for OCD specifies that the patient’s compulsive rituals must take more than one hour each day to perform.

In addition to the inclusion criteria, symptoms that must be present, many disorders are also defined in terms of certain exclu- sion criteria. In other words, the diagnosis can be ruled out if certain conditions prevail. For example, in the case of OCD, the diagnosis would not be made if the symptoms were the product of using drugs or the presence of another medical condition (cri- terion “C”). Finally, OCD would not be considered as the diag- nosis if the symptoms were part of another mental disorder, such as a seriously depressed person being preoccupied with guilty ruminations (criterion “D”).

Clinical disorders are defined largely in terms of symptom- atic behaviors. Most diagnoses, such as OCD, schizophrenia, and depressive disorders, are characterized by episodic periods of psychological turmoil. A person can be assigned more than one diagnosis if he or she meets criteria for more than one disorder.

Michael would receive a primary diagnosis of obsessive– compulsive disorder. His obsessions and compulsions were, in fact, his most obvious symptoms. Michael would also be

82 CHAPTER 4 classification and assessment of abnormal behavior

Labels and Stigma

What does it mean to be labeled with a psychiatric diagnosis? Labeling theory is a perspective on mental disorders that is primarily concerned with the negative consequences of assigning a diagnostic label, especially the impact that diagnosis has on ways in which people think about themselves and the ways in which other people react to the designated patient (Link & Phelan, 2010). It as- signs relatively little importance to specific behaviors as symptoms of a disorder that resides within the per- son. Labeling theory is primarily concerned with social factors that determine whether a person will be given a psychiatric diagnosis rather than the psychological or biological reasons for the abnormal behaviors. In other words, it is concerned with events that take place after a person has behaved in an unusual way rather than with factors that might explain the original appearance of the behavior itself.

According to contemporary versions of labeling theory, pub- lic attitudes toward mental illness shape a person’s reaction to being assigned a diagnosis. Influenced by negative beliefs about people with mental disorders (such as “they are less competent,” or “they are dangerous”), the person may try to avoid rejection by withdrawing from interactions with other people. Unfortunately, this withdrawal can lead to further isolation and diminished levels of social support (Kroska & Harkness, 2006).

The probability that a person will receive a diagnosis is presumably determined by several factors, including the severity of the unusual behavior. Beyond the nature of the disorder itself, however, the social context in which the problem occurs and the tolerance level of the community are also important. The labeling theory perspective places considerable emphasis on the social status of the person who exhibits abnormal behavior and the social distance be- tween that person and mental health professionals. People from disadvantaged groups, such as racial and sexual minori- ties and women, are presumably more likely to be labeled than are white males.

The merits and limitations of labeling theory have been debated extensively. The theory has inspired research on a number of important questions. Some studies have found that people from lower status groups, including racial minori- ties, are indeed more likely to be assigned severe diagnoses (Phelan & Link, 1999). On the other hand, it would also be an exaggeration to say that the social status of the patient is the most important factor influencing the diagnostic process. In fact, clinicians’ diagnostic decisions are determined primar- ily by the form and severity of the patient’s symptoms rather

than by such factors as gender, race, and social class (Ruscio, 2004).

Another focus of the debate regarding labeling theory is the issue of stigma and the negative effects of labeling. Stigma refers to a stamp or label that sets the person apart from others, connects the person to undesirable features, and leads others to reject the person. Labeling theory notes that negative attitudes toward mental disorders prevent patients from obtaining jobs, finding housing, and forming new relationships. Various kinds of empirical evidence support the conclusion that a psychiatric label can have a harmful impact on a person’s life. Negative attitudes are associ- ated with many types of mental disorders, such as alcoholism, schizophrenia, and sexual disorders. When people become psy- chiatric patients, many expect to be devalued and discriminated against (Couture & Penn, 2003; Yang et al., 2007). These expecta- tions could cause the person to behave in strained and defensive ways, which may in turn lead others to reject him or her.

Labeling theory has drawn needed attention to several impor- tant problems associated with the classification of mental dis- orders. Of course, it does not provide a complete explanation for abnormal behavior. Many factors other than the reactions of other people contribute to the development and maintenance of abnormal behavior. It is also important to realize that a diag- nosis of mental illness can have positive consequences, such as encouraging access to effective treatment. Many patients and their family members are relieved to learn that their problems are similar to those experienced by other people and that help may be available. The effects of diagnostic labeling are not always harmful.

Demonstrators rally outside the U.S. capitol to combat stigma and support a bill that would require health insurance companies to pro- vide equal coverage for mental health and addiction treatment.

classification and assessment of abnormal behavior CHAPTER 4 83

coded as meeting criteria for schizotypal personality disorder (see Chapter 9). This judgment depends on a consideration of his long-standing, relatively rigid patterns of interacting with other people and his inability to adjust to the changing requirements of different people and situations. For example, he was suspicious of other people’s motives, he did not have any close friends in whom he could confide, and he was very anxious in social situations because he was afraid that other people might take advantage of him. These are important considerations for a therapist who wants to plan a treatment program for Michael, but they are relatively subtle consid- erations in comparison to the obsessions and compulsions, which were currently the primary source of conflict with his parents.

Culture and Classification DSM-5 addresses the relation between cultural issues and the diagnosis of psychopathology in two principal ways. First, the

manual encourages clinicians to consider the influence of cultural factors in both the expression and recognition of symptoms of mental disorders. People express extreme emotions in ways that are shaped by the traditions of their families and other social groups to which they belong. Intense, public displays of anger or grief might be expected in one culture but considered signs of disturbance in another. Interpretations of emotional distress and other symptoms of disorder are influenced by the explanations that a person’s culture assigns to such experiences. Religious be- liefs, social roles, and sexual identities all play an important part in constructing meanings that are assigned to these phenomena (Hwang et al., 2008). The accuracy and utility of a clinical di- agnosis depend on more than a simple count of the symptoms that appear to be present. They also hinge on the clinician’s abil- ity to consider the cultural context in which the problem ap- peared. This is a particularly challenging task when the clinician and the person with the problem do not share the same cultural background.

DSM-5Obsessive-Compulsive Disorder A. Presence of obsessions, compulsions, or both. Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2): 1. Repetitive behaviors (e.g., hand washing, ordering,

checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant

distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

criteria for

84 CHAPTER 4 classification and assessment of abnormal behavior

The diagnostic manual also attempts to sensitize clinicians to cultural issues by including a discussion of cultural concepts of distress. These are patterns of erratic or unusual thinking and behavior that have been identified in diverse societies around the world and do not fit easily into the other diagnostic categories that are listed in the main body of DSM-5. They are considered to be unique to particular societies, particularly in non-Western or developing countries. Their appearance is easily recognized and understood to be a form of abnormal behavior by members of certain cultures, but they do not conform to typical patterns of mental disorders seen in the United States or Europe. The cultural concepts of distress have also been called culture-bound syndromes or idioms of distress. In other words, they represent a manner of expressing negative emotion that is unique to a par- ticular culture and cannot be easily translated or understood in terms of its individual parts.

One concept or syndrome of this type is known as ataques de nervios, which has been observed most extensively among people from Puerto Rico and other Caribbean countries (Lewis-Fernán- dez et al., 2002; San Miguel et al., 2006). Descriptions of this experience include four dimensions, in which the essential theme is loss of control—an inability to interrupt the dramatic sequence of emotion and behavior. These dimensions include emotional expressions (an explosion of screaming and crying, coupled with overwhelming feelings of anxiety, depression, and anger), bodily sensations (including trembling, heart palpitations, weakness, fatigue, headache, and convulsions), actions and behaviors (dra- matic, forceful gestures that include aggression toward others, suicidal thoughts or gestures, and trouble eating or sleeping), and alterations in consciousness (marked feelings of “not being one’s usual self,” accompanied by fainting, loss of consciousness, dizzi- ness, and feelings of being outside of one’s body).

Ataques are typically provoked by situations that disrupt or threaten the person’s social world, especially the family. Many ataques occur shortly after the person learns unexpectedly that a close family member has died. Others result from an imminent di- vorce or after a serious conflict with a child. Women are primarily responsible for maintaining the integrity of the family in this cul- ture, and they are also more likely than men to experience ataques de nervios. Puerto Rican women from poor and working-class families define themselves largely in terms of their success in building and maintaining a cohesive family life. When this social role is threat- ened, an ataque may result. This response to threat or conflict—an outburst of powerful, uncontrolled negative emotion—expresses suffering while simultaneously providing a means for coping with the threat. It serves to signal the woman’s distress to important other people and to rally needed sources of social support.

What is the relation between cultural concepts of distress and the formal categories listed in DSM-5? The answer is unclear and also varies from one syndrome to the next. Are they simi- lar problems that are simply given different names in other cul- tures? Probably not, at least not in most instances (Guarnaccia & Pincay, 2008). In some cases, people who exhibit behavior that

would fit the definition of a cultural concepts of distress would also qualify for a DSM-5 diagnosis, if they were diagnosed by a clinician trained in the use of that manual (Tolin et al., 2007). But everyone who displays the cultural concepts of distress would not meet criteria for a DSM-5 disorder, and of those who do, not all would receive the same DSM-5 diagnosis.

The discussion of cultural concepts of distress has been praised as a significant advance toward integrating cultural con- siderations into the classification system (Lopez & Guarnaccia, 2000). It has also been criticized for its ambiguity. The most dif- ficult conceptual issue involves the boundary between these syn- dromes and categories found elsewhere in the diagnostic manual. Some critics have argued that they should be fully integrated, without trying to establish a distinction (Hughes, 1998). Others have noted that if culturally unique disorders must be listed sepa- rately from other, “mainstream” conditions, then certain disorders now listed in the main body of the manual—especially eating disorders, such as bulimia—should actually be listed as cultural concepts of distress. Like ataques de nervios, bulimia nervosa is a condition that is found primarily among a limited number of cultures (Keel & Klump, 2003). The difference is that bulimia is found in our culture—people living in Western or developed countries—rather than in other cultures. Dissociative amnesia— the inability to recall important personal information regarding a traumatic event—also resembles cultural concepts of distress be- cause it appears to be experienced only by people living in mod- ern, developed cultures (Pope et al., 2007).

Thinking about this distinction helps to place the more fa- miliar diagnostic categories in perspective and shows how our own culture has shaped our views of abnormal behavior. We must not be misled into thinking that culture shapes only conditions that appear to be exotic in faraway lands; culture shapes various facets of all disorders. Though it is imperfect, the consideration of cultural concepts of distress does serve to make clinicians more aware of the extent to which their own views of what is normal and abnormal have been shaped by the values and experiences of their own culture (Mezzich, Berganza, & Ruiperez, 2001).

Just as judges sometimes disagree in their assessment of evidence presented during a trial, psychologists and psychiatrists do not always agree on how various disorders should be diagnosed. Of course, both judges and mental health professionals attempt to be reliable (consistent) in their judgments.

classification and assessment of abnormal behavior CHAPTER 4 85

Evaluating Classification Systems One of the most important things to understand about the classifica- tion of mental disorders is that the official diagnostic manual is re- vised on a regular basis. That process is guided by research on mental disorders, and the evidence takes many forms. How can we evaluate a system like DSM-5? Is it a useful classification system? Utility can be measured in terms of two principal criteria: reliability and validity.

Reliability Reliability refers to the consistency of measurements, includ- ing diagnostic decisions. If a diagnosis is to be useful, it will have to be made consistently. One important form of reliabil- ity, known as “interrater reliability,” refers to agreement between clinicians who are provided with exactly the same information.

Suppose, for example, that two psychologists watch the same video recording of an interview with a patient and that each psychologist independently assigns a diagnosis using DSM-5. If both psychologists decide that the patient fits the criteria for a major depressive disorder, they have used the definition of that category consistently. A more difficult challenge involves “test–retest reliability.” This situation may yield lower levels of consistency because the patient’s condition could change between the two assessments (and both clinicians would not have exactly the same information). Of course, one or two cases would not provide a sufficient test of the reliability of a diagnostic category. The real question is whether the clinicians would agree with each other over a large series of patients. The process of collecting and interpreting information regarding the reliability of diagnosing mental disorders is discussed in Research Methods below.

RESEARCH methods

Reliability: Agreement Regarding Diagnostic Decisions

Several formal procedures have been developed to evaluate diagnostic reliability. Most studies of psychiat-ric diagnosis employ an index known as kappa. Instead of measuring the simple proportion of agreement between clinicians, kappa indicates the proportion of agreement that occurred above and beyond that which would have occurred by chance. Negative values of kappa indicate that the rate of agreement was less than that which would have been expected by chance in this particular sample of people. Thus, kappa of zero indicates chance agreement, and a kappa of 1.0 indicates perfect agreement between raters.

How should we interpret the kappa statistic? There is no easy answer to this question (Kraemer et al., 2012). It would be un- realistic to expect perfect consistency, especially in view of the relatively modest reliability of some other types of diagnostic decisions that are made in medical practice (Garb, Klein, & Grove, 2002; Meyer et al., 2001). On the other hand, it isn’t very encouraging simply to find that the level of agreement among clinicians is a bit better than chance. We should expect more than that from a diagnostic system, especially when it is used as a basis for treatment decisions. One traditional convention sug- gests that kappa values of .70 or higher indicate relatively good agreement, but that is a standard that is seldom met outside of highly controlled research situations, using specially trained rat- ers, structured diagnostic interviews, and highly selected patient samples. Values of kappa below .40 are often interpreted as in- dicating questionable or poor agreement.

The reliability of many diagnostic categories is better than it was many years ago, in part, because clinicians use more detailed diagnostic criteria to define specific disorders. Still, most studies also indicate that there is considerable room for improvement.

The reliability of some diagnostic categories remains open to serious question. Consider, for example, evidence from field trials that were conducted by the American Psychiatric Associa- tion when DSM-5 was being prepared (Regier et al., 2013). Data were collected by a large number of mental health professionals at several large medical centers, using representative samples of patients from each center. The field trials followed a test–re- test design. Each patient was interviewed by a clinician, who recorded a diagnosis. A second clinician then independently conducted a second interview with the same patient, and that person also recorded a diagnosis. The follow-up interviews oc- curred at least four hours and not more than two weeks after the initial interview in order to minimize the chance that the patient’s clinical condition changed between the assessments (either spontaneous recovery or the onset of a new disorder). Struc- tured diagnostic interviews were not employed because they are seldom used in standard clinical practice. This design provided a fair estimate of the reliability of the DSM-5 diagnostic criteria as they would be used in actual clinical practice.

Kappa values for several diagnostic categories are presented in Figure 4.1. The data are presented separately for a few represen- tative adult and childhood diagnoses, and they are organized on the basis of levels of agreement. Relatively few diagnostic catego- ries showed “very good” agreement, defined in terms of kappa higher than .60. The diagnostic reliability for several categories was “good,” if we take values of kappa between .40 and .60 as the criterion for that judgment. It should also be noted that quite a few categories demonstrated “questionable” levels of reliability, including major depressive disorder and generalized anxiety dis- order (two of the most frequently employed diagnostic categories in DSM-5). This pattern of results is clearly mixed; it is reassuring for some disorders and somewhat alarming for others.

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86 CHAPTER 4 classification and assessment of abnormal behavior

Validity The most important issue in the evaluation of a diagnostic cat- egory is whether it is useful (Kendell & Jablensky, 2003). By knowing that a person fits into a particular group or class, do we learn anything meaningful about that person? For example, if a person fits the diagnostic criteria for schizophrenia, is that person likely to improve when he or she is given antipsychotic medica- tion? Or is that person likely to have a less satisfactory level of so- cial adjustment in five years than a person who meets diagnostic criteria for bipolar disorder? Does the diagnosis tell us anything about the factors or circumstances that might have contributed to the onset of this problem? These questions are concerned with the validity of the diagnostic category. The term validity refers

to the meaning or importance of a measurement—in this case, a diagnostic decision (Kraemer, 2010). Importance is not an “all- or-none” phenomenon; it is a quantitative issue. Diagnostic cat- egories are more or less useful, and their validity (or utility) can be determined in several ways.

Validity is, in a sense, a reflection of the success that has been achieved in understanding the nature of a disorder. Have impor- tant facts been discovered? Systematic studies aimed at establishing the validity of a disorder may proceed in a sequence of phases (Robins & Guze, 1989), such as those listed in Table 4.1. After a clinical description has been established, diagnostic categories are refined and validated through this process of scientific explora- tion. It should be emphasized, however, that the sequence listed in

This evidence from the DSM-5 field trials suggests that we should not accept uncritically the assumption that the diagnostic cat- egories in DSM-5 can be used reliably (Jones, 2012). Cautious skepticism is clearly warranted when clinicians use these terms to organize information and communicate with each other and with their patients about the nature of mental health problems. On the other hand, we should also welcome the efforts that were made to evaluate and describe levels of diagnostic reliability that

might be expected for the revised diagnostic manual. And finally, we should keep in mind the fact that, in actual clinical practice, mental disorders are seldom diagnosed on the basis of a single interview. It is important for clinicians to consider a wide range of information for each person, including the results of various assessment procedures and consultation with more than one source (e.g., other family members).

FIGURE 4.1 Test–retest Reliability of Diagnoses from the DSM-5 Field Trials Source: From R. Freedman, D. A. Lewis, R. Michels, D. S. Pine, S. K. Schultz, C. A. Tamminga,. . . . & J. Yager, 2013, “The initial field trials of DSM-5: New Blooms and old thorns,” American Journal of Psychiatry, 170, 1–5

0.1 0.2 0.3 0.4 0.5 0.6 0.70

Posttraumatic stress disorder

Bipolar I disorder

Binge eating disorder

Borderline personality disorder

Schizophrenia

Alcohol use disorder

Major depressive disorder

Antisocial personality disorder

Generalized anxiety disorder

Child Diagnoses

Adult Diagnoses

Autism spectrum disorder

Attention deficit hyperactivity disorder

Conduct disorder

0.67

0.56

0.56

0.54

0.46

0.40

0.28

0.21

0.20

0.69

0.61

0.46

Very good agreement Good agreement Questionable agreement

classification and assessment of abnormal behavior CHAPTER 4 87

Table 4.1 represents an ideal scenario. Relatively few, if any, of the disorders listed in DSM-5 are supported by an extensive set of research evidence supporting all these points. Clinical scientists have not identified “points of rarity” between related syndromes (McGuffin & Farmer, 2005). For most disorders, the evidence regarding long-term outcome and treatment response varies con- siderably from one person to the next. You should not assume that the types of studies listed in Table 4.1 have all provided unequivo- cal support for the validity of the disorders listed in DSM-5.

It may be helpful to think of different forms of validity in terms of their relationship in time with the appearance of symptoms of the disorder. Etiological validity is concerned with factors that cause or contribute to the onset of the disorder. These are things that have happened in the past. Was the disorder regularly triggered by a spe- cific set of events or circumstances? Did it run in families? The ulti- mate question with regard to etiological validity is whether there are any specific causal factors that are regularly, and perhaps uniquely, associated with this disorder. If we know that a person exhibits the symptoms of the disorder, do we in turn learn anything about the circumstances that originally led to the onset of the problem?

Concurrent validity is concerned with the present time and with correlations between the disorder and other symptoms, cir- cumstances, and test procedures. Is the disorder currently associ- ated with any other types of behaviors, such as performance on psychological tests? Do precise measures of biological variables, such as brain structure and function, distinguish reliably between

people who have the disorder and those who do not? Clinical studies that are aimed at developing a more precise description of a disorder also fall into this type of validity.

Predictive validity is concerned with the future and with the stability of the problem over time. Will it be persistent? If it is short-lived, how long will an episode last? Will the disor- der have a predictable outcome? Do people with this problem typically improve if they are given a specific type of medication or a particular form of psychotherapy? The overall validity of a diagnostic category depends on the body of evidence that accu- mulates as scientists seek answers to these questions.

The list of categories included in DSM-5 is based on the re- sults of research studies as well as clinical experience. Some disor- ders are based on a much more extensive foundation of evidence than others. Each time the manual is revised, new categories are added and old categories are dropped, presumably because they are not sufficiently useful. Up to the present time, clinicians have been more willing to include new categories than to drop old ones. It is difficult to know when we would decide that a particular diag- nostic category is not valid. At what point in the accumulation of knowledge are clinical scientists willing to conclude that a category is of no use and to recommend that the search for more informa- tion should be abandoned? This is a difficult question that the au- thors of each revision of the diagnostic manual must confront. The situation regarding validity and psychiatric diagnosis is an evolving process, with more evidence being added on a regular basis.

TABLE 4.1 Types of Studies Used to Validate Clinical Syndromes Identification and description of the syndrome, either by clinical intuition or by statistical analyses.

Demonstration of boundaries or “points of rarity” between related syndromes.

Follow-up studies establishing a distinctive course or outcome.

Therapeutic trials establishing a distinctive treatment response.

Family studies establishing that the syndrome “breeds true.”

Demonstration of association with some more fundamental abnormality—psychological, biochemical, or molecular.

Source: Based on Kendall, R.E. 1989. “Clinical Validity,” Psychology Medicine, 19(1).

THINKING CRITICALLY about DSM-5

Scientific Progress or Diagnostic Fads?

Everyone agrees that the official diagnostic manual needs to be updated periodically to bring it into closer alignment with current knowledge and practice. But what principles and standards should guide that process? When DSM-III was re- vised to produce DSM-IV, the workgroups were instructed to fol- low a rather conservative principle: “Don’t make changes unless there is clear scientific evidence to support the change.” The au- thors of DSM-5 set out with a more expansive and open-minded

view of their task (Kupfer, First, & Regier, 2002). They recognized that larger changes might be needed in order to “transcend the limitations of the DSM paradigm,” and they wanted to “en- courage thinking beyond the DSM-IV framework.” Workgroups were told that “there are no preset limitations on the number of changes that may occur” (Kupfer, Regier, & Kuhl, 2008). This shift in emphasis generated quite a bit of controversy as the revision unfolded (Frances & Widiger, 2012).

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88 CHAPTER 4 classification and assessment of abnormal behavior

Problems and Limitations of the DSM-5 System Many experts believe that DSM-5 is an improvement over ear- lier versions of APA’s classification system, but the manual has already been criticized extensively, often with good reason. One fundamental question that applies to every disorder involves the boundary between normal and abnormal behavior. This is a long- standing problem in the classification of mental disorders. The definitions that are included in the manual are often vague with regard to this threshold (Frances & Widiger, 2012). DSM-5 is based on a categorical approach to classification, but most of the symptoms that define the disorders are actually dimensional in nature. Depressed mood, for example, can vary continuously from the complete absence of depression to moderate levels of depression on up to severe levels of depression. The same thing can be said with regard to symptoms of anxiety disorders, eating disorders, and substance use disorders. These are all continuously distributed phenomena, and there is not a bright line that divides people with problems from those who do not have problems.

The absence of a specific definition of social impairment is another practical issue that plagued previous versions of the diag- nostic manual. Most disorders in DSM-5 include the requirement

that a particular set of symptoms causes “clinically significant distress or impairment in social or occupational functioning.” No specific measurement procedures are provided to make this determination. Mental health professionals must rely on their own subjective judgment to decide how distressed or how impaired a person must be by his or her symptoms in order to qualify for a diagnosis. There is an important need for more specific defini- tions of these concepts, and better measurement tools are needed for their assessment.

Criticisms of the current classification system have also emphasized broad conceptual issues. Some clinicians and inves- tigators have argued that the syndromes defined in DSM-5 do not represent the most useful ways to think about psychological problems, either in terms of planning current treatments or in terms of designing programs of research. For example, it might be better to focus on more homogeneous dimensions of dysfunc- tion, such as anxiety or angry hostility, rather than on syndromes (groups of symptoms) (Smith & Combs, 2010).

Critics pose questions such as: Should we design treatments for people who exhibit distorted, negative ways of thinking about themselves, regardless of whether their symptoms happen to

New disorders are considered for inclusion in the diagnostic manual every time that it is revised. Changes were particularly evident this time around, given the less conservative tone that was set at the outset of the process. In the end, some of the proposals for new disorders were accepted, and others were not. New disorders include binge eating disorder, disruptive mood regulation disorder, and premenstrual dysphoric disorder. They are controversial, in part, because they are likely to be among the most frequently diagnosed conditions in the manual, expanding substantially the overall prevalence of mental disor- ders in the general population. It is also reasonable to wonder if these new diagnostic categories provide the best possible explanation for the adjustment problems that they describe (see Critical Thinking Matters in Chapter 1). Strong fluctuations in mood and struggles with impulse control may be part of normal human experience rather than manifestations of disorder.

Among those new disorders that were considered and ultimately rejected, some were included in Section III of DSM-5, which is an appendix that describes “Emerging Measures and Models.” These are disorders that require further study, and they may eventually be moved into the main body of the manual. Several controversial forms of behavioral problems are included in Sec- tion III, including: attenuated psychosis syndrome (see Thinking Critically About DSM-5 in Chapter 13), Internet gaming disorder, and persistent complex bereavement disorder. These proposals for new diagnostic categories all include behavioral issues, emo- tional distress, and adjustment difficulties that affect large num- bers of people. Many of these people seek professional help,

and mental health professionals would like to have a way to categorize these forms of distress. On the other hand, it is also reasonable to wonder if the creation of a new, formal diagnostic category is the best way to handle the situation. What is the downside to this wholesale expansion of the diagnostic manual? One persuasive critique of DSM-5 argued, “Fads punctuate what has become a basic background of overdiagnosis. Normality is an endangered species” (Frances & Widiger, 2012).

In the absence of a universally accepted definition of mental disorder (see Chapter 1), a definition that would identify an obvi- ous boundary between normal and abnormal behavior, decisions about which problems are included in the diagnostic manual will necessarily be made on the basis of social processes. These include pressures from patients’ advocates, mental health profes- sionals, insurance companies, and the pharmaceutical industry. All of these groups express, in one way or another, the understand- able desire to identify and explain psychological problems that are a source of distress or social impairment. Research evidence is certainly considered when the diagnostic manual is revised, but these data do not represent huge scientific breakthroughs that identify major causal pathways responsible for the etiology of these conditions. Rather, this evidence tends to be concerned with the efficiency and utility of various options for describing each disorder, the connections between diagnostic procedures and efficacy of treatment procedures, and so on. The bottom line is that the new categories included in DSM-5 probably re- flect diagnostic fads more than scientific breakthroughs. But we shouldn’t really expect more than that. It’s still a useful manual.

classification and assessment of abnormal behavior CHAPTER 4 89

involve a mixture of depression, anxiety, or some other pattern of negative emotion or interpersonal conflict? The answer is: We don’t know. It would certainly be premature to cut off consider- ation of these alternatives just because they address problems in a way that deviates from the official diagnostic manual. In our current state of uncertainty, diversity of opinion should be en- couraged, particularly if it is grounded in cautious skepticism and supported by rigorous scientific inquiry.

From an empirical point of view, DSM-5 is hampered by a number of problems that suggest that it does not classify clini- cal problems into syndromes in the simplest and most beneficial way (Helzer, Kraemer, & Krueger, 2006). One of the thorniest issues involves comorbidity, which is defined as the simultaneous appearance of two or more disorders in the same person. Comor- bidity rates are very high for mental disorders as they are defined in the DSM system (Eaton, South, & Krueger, 2010). For ex- ample, in the National Comorbidity Survey, among those people who qualified for at least one diagnosis at some point during their lifetime, 56 percent met the criteria for two or more disorders. A small subgroup, 14 percent of the sample, actually met the diag- nostic criteria for three or more lifetime disorders. That group of people accounted for almost 90 percent of the severe disorders in the study.

There are several ways to interpret comorbidity (Krueger, 2002). Some people may independently develop two separate conditions. In other cases, the presence of one disorder may lead to the onset of another. Unsuccessful attempts to struggle with prolonged alcohol dependence, for example, might lead a person

to become depressed. Neither of these alternatives creates concep- tual problems for DSM-5. Unfortunately, the very high rate of comorbidity suggests that these explanations account for a small proportion of overlap between categories.

The real problem associated with comorbidity arises when a person with a mixed pattern of symptoms, usually of a severe nature, simultaneously meets the criteria for more than one dis- order. Consider, for example, a client who was treated by one of the authors of this text. This man experienced a large number of diffuse problems associated with anxiety, depression, and inter- personal difficulties. According to the DSM-5 system, he would have met the criteria for major depressive disorder, generalized anxiety disorder, and obsessive–compulsive disorder, as well as three types of personality disorders. It might be said, therefore, that he suffered from at least six types of mental disorders. But is that really helpful? Is it the best way to think about his problems? Would it be more accurate to say that he had a complicated set of interrelated problems that were associated with worrying, rumi- nation, and the regulation of high levels of negative emotion and that these problems constituted one complex and severe type of disorder?

The comorbidity issue is related to another limitation of DSM-5: the failure to make better use of information regard- ing the course of mental disorders over time. More than 100 years ago, when schizophrenia and bipolar mood disorder were originally described, the distinction between them was based heavily on observations regarding their long-term course. Un- fortunately, most disorders listed in DSM-5 are defined largely

This warning system for fire danger is an example of a dimensional classification system. It conveys informa- tion about “how much dan- ger” is present rather than simply indicating that the situation is either dangerous or not dangerous.

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in terms of snapshots of symptoms at particular points in time. Diagnostic decisions are seldom based on a comprehensive analysis of the way that a person’s problems evolve over time. If someone meets the criteria for more than one disorder, does it matter which one came first? Is there a predictable pattern in which certain disorders follow the onset of others? What is the nature of the connection between childhood disorders and adult problems? Our knowledge of mental disorders would be greatly enriched if greater emphasis were placed on questions regard- ing life span development (Buka & Gilman, 2002; Oltmanns & Balsis, 2011).

These issues will be debated by mental health experts for many years to come. It seems unlikely that they will be solved in the near future. Attempts to provide solutions to these prob- lems and limitations will ensure that the classification system will continue to be revised. As before, these changes will be driven by the interaction of clinical experience and empirical evidence. Students, clinicians, and research investigators should all remain skeptical when using this classification system and its successors.

Basic Issues in Assessment Up to this point, we have discussed the development and use of classification systems. But we haven’t talked about the way in which a psychologist might collect the information that is nec- essary to arrive at a diagnostic decision. Furthermore, we have looked at the problem only in relatively general terms. The di- agnostic decision is one useful piece of information. It is not, however, a systematic picture of the specific person’s situation. It is only a starting point. In the following section we extend our discussion to consider methods of collecting information. In so doing, we discuss a broad range of data that may be useful in un- derstanding psychopathological behavior.

Purposes of Clinical Assessment To appreciate the importance and complexity of assessment pro- cedures, let’s go back to the example of Michael. When Michael and his parents initially approached the psychologist, they were clearly upset. But the nature of the problem, in terms of Michael’s behavior and the family as a whole, was not clearly defined. Before he could attempt to help this family, the psychologist had to col- lect more information. He needed to know more about the range and frequency of Michael’s obsessions and compulsions, includ- ing when they began, how often he experienced these problems, and the factors that made them better or worse. He also needed to know whether there were other problems, such as depression or delusional beliefs that might either explain these responses or interfere with their treatment. In addition, he had to learn how Michael got along with classmates, how he was doing in school, and how his parents responded when he behaved strangely. Was his behavior, at least in part, a response to environmental circum- stances? How would the family support (or interfere with) the

therapist’s attempts to help him change? The psychologist needed to address Michael’s current situation in terms of several different facets of his behavior.

Psychological assessment is the process of collecting and in- terpreting information that will be used to understand another person. Numerous data-gathering techniques can be used in this process. Several of these procedures are described in the following pages. We must remember, however, not to confuse the process of assessment with this list of techniques. Assessment procedures are tools that can be used in many ways. They cannot be used in an intellectual vacuum. The person who conducts the assessment must adopt a theoretical perspective regarding the nature of the disorders that are being considered and the causal processes that are involved in their origins (see Chapter 2). Interviews can be used to collect all sorts of information for all sorts of reasons. Psy- chological tests can be interpreted in many different ways. The value of assessment procedures can be determined only in the context of a specific purpose (McFall, 2005).

Assessment procedures can be used for several purposes. Perhaps most obvious is the need to describe the nature of the person’s principal problem. This goal typically involves making a diagnosis. The clinician must collect information to support the diagnostic decision and to rule out alternative explanations for the symptoms. Assessment procedures are also used for making predic- tions, planning treatments, and evaluating treatments. The practical importance of predictions should be obvious: Many crucial deci- sions are based on psychologists’ attempts to determine the prob- ability of future events. Will a person engage in violent behavior? Can a person make rational decisions? Is a parent able to care for his or her children? Assessment is also commonly used to evaluate the likelihood that a particular form of treatment will be helpful for a specific patient and to provide guideposts by which the effectiveness of treatment programs can be measured. Different assessment pro- cedures are likely to be employed for different purposes. Those that are useful in one situation may not be helpful in another.

Diagnostic interviews provide an opportunity to make detailed inquiries about a person’s subjective experience while also observing his or her behavior.

classification and assessment of abnormal behavior CHAPTER 4 91

Assumptions About Consistency of Behavior Assessment involves the collection of specific samples of a per- son’s behavior. These samples may include things that the per- son says during an interview, responses that the person makes on a psychological test, or things that the person does while be- ing observed. None of these would be important if we assumed that they were isolated events. They are useful to the extent that they represent examples of the ways in which the person will feel or behave in other situations. Psychologists, therefore, must be concerned about the consistency of behavior across time and situations. They want to know if they can generalize, or draw in- ferences about the person’s behavior in the natural environment on the basis of the samples of behavior that are obtained in their assessment. If the client is depressed at this moment, how did she feel one week ago, and how will she feel tomorrow? In other words, is this a persistent phenomenon, or is it a temporary state? If a child is anxious and unable to pay attention in the psycholo- gist’s office, will he also exhibit these problems in his classroom? And how will he behave on the playground?

Psychologists typically seek out more than one source of in- formation when conducting a formal assessment. Because we are trying to compose a broad, integrated picture of the person’s ad- justment, we must collect information from several sources and then attempt to integrate these data. Each piece of information may be considered to be one sample of the person’s behavior. One way of evaluating the possible meaning or importance of this in- formation is to consider the consistency across sources. Do the conclusions drawn on the basis of a diagnostic interview agree with those that are suggested by a psychological test? Do the psy- chologist’s observations of the client’s behavior and the client’s self-report agree with observations that are reported by parents or teachers?

Evaluating the Usefulness of Assessment Procedures The same criteria that are used to evaluate diagnostic categories are used to evaluate the usefulness of assessment procedures: re- liability and validity. In the case of assessment procedures, reli- ability can refer to various types of consistency. For example, the consistency of measurements over time is known as test–retest re- liability. Will a person receive the same score if an assessment pro- cedure is repeated at two different points in time? The internal consistency of items within a test is known as split-half reliability. If a test with many items measures a specific trait or ability, and if the items are divided in half, will the person’s scores on the two halves agree with each other? Assessment procedures must be reli- able if they are to be useful in either clinical practice or research.

The validity of an assessment procedure refers to its meaning or importance (Meyer et al., 2001; Strauss & Smith, 2009). Is the person’s score on this test or procedure actually a reflection of the trait or ability that the test was designed to measure? And does the score tell us anything useful about the person’s behavior in other

situations? Knowing that the person has achieved a particular score on this evaluation, can we make meaningful predictions about the person’s responses to other tests or about his or her behavior in future situations? These are all questions about the validity of an assessment procedure. In general, the more consistent the informa- tion provided by different assessment procedures, the more valid each procedure is considered to be (see Critical Thinking Matters).

Cultural differences present an important challenge to the validity of assessment procedures. It is often difficult to under- stand the thoughts and behaviors of people from a cultural back- ground that is different from our own. Measurement procedures that were constructed for one group may be misleading when they are applied to people from another culture. Language, reli- gion, gender roles, beliefs about health and illness, and attitudes toward the family can all have an important impact on the ways in which psychological problems are experienced and expressed. These factors must be taken into consideration when psycholo- gists collect information about the nature of a specific person’s

Every assessment device has its own strengths and weaknesses. Each presents a somewhat different (and perhaps limited or distorted) per- spective on the person.

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problems. Interviews, observational procedures, and personal- ity tests must be carefully evaluated for cross-cultural validity (Padilla, 2001). Unfortunately, this issue has often been overlooked in treatment planning and in psychopathology research. We should not assume that a questionnaire developed in one culture will necessarily be useful in another. Investigators must demonstrate empirically that it measures the same thing in both groups.

Psychological Assessment Procedures Our purpose in the rest of this chapter is to outline a range of assessment procedures. This is a selective sampling of measures rather than an exhaustive review. We begin our discussion with psychological assessment procedures, ranging from interviews to various kinds of psychological tests. The last section of this chapter is concerned with biological assessment procedures that tap neurological and biochemical events that are associated with mental disorders.

“Person variables” are typically the first things that come to mind when we think about the assessment of psychopathology. What did the person do or say? How does the person feel about his or her current situation? What skills and abilities does the person possess, and are there any important cognitive or social

deficits that should be taken into consideration? These questions about the individual person can be addressed through a number of procedures, including interviews, observations, and various types of self-report instruments and psychological tests.

Interviews Often, the best way to find out about someone is to talk with that person directly. The clinical interview is the most commonly used procedure in psychological assessment. Most of the categories that are defined in DSM-5 are based on information that can be collected in an interview. These data are typically supplemented by information that is obtained from official records (previous hospital or clinic admissions, school reports, court files) and in- terviews with other informants (e.g., family members), but the clients’ own direct descriptions of their problems are the primary basis for diagnostic decisions. Except for decisions regarding in- tellectual disability, none of the diagnostic categories in DSM-5 is defined in terms of psychological or biological tests.

Interviews provide an opportunity to ask people for their own descriptions of their problems. Many of the symptoms of psycho- pathology are subjective, and an interview can provide a detailed analysis of these problems. Consider, for example, Michael’s problems with anxiety. The unrelenting fear and revulsion that

CRITICAL THINKING matters

The Barnum Effect and Assessment Feedback

Lots of people believe that psychologists can read minds. Unfor- tunately, assessment procedures used by psychologists do not provide a magic window into the psyche. Many procedures have been developed to collect information about human behavior and clinical problems. Each has its own strengths and weaknesses. None is infallible.

If psychologists do make errors, why do people often accept the results of their assessments uncritically? In a classic essay, Paul Meehl (1973) described a problem that he called the Barnum Effect, after P. T. Barnum, the brilliant and shameless promoter who founded the circus called “The Greatest Show on Earth.” The Barnum effect re- fers to the practice of saying things about a specific person that are true of virtually all people. For example, imagine that the psycholo- gist working with Michael had conducted a formal psychological assessment and concluded that Michael had ambivalent feelings about his parents, that he was sometimes lacking in self-confidence, or that his expectations were sometimes unrealistic. People often accept such vague or superficial statements as being meaning- ful comments about themselves, failing to understand that vague generalizations like these apply to almost everyone. Clearly, psycho- logical assessment should be held to a higher standard. Diagnostic decisions and clinical judgments should contain meaningful, specific information.

What can we do to improve the validity of psychological assess- ments? One important step is to recognize their fallibility. Like ev- eryone else, clinical psychologists are prone to a variety of cognitive biases and errors in decision making (Garb, 2005). Under conditions of uncertainty, they use mental shortcuts to make clinical judgments. For example, they pay too much attention to information that confirms their initial impressions, and they tend to ignore informa- tion that is inconsistent with these impressions. They can be unduly influenced by vivid, individual cases that come readily to mind and sometimes fail to consider more important evidence based on data from large samples. The impact of these cognitive biases might be minimized if clinicians would deliberately consider alternative hy- potheses (such as a diagnosis other than their first impression) and then consider evidence that would either support or disconfirm that possibility.

If you think about it for a moment, you probably will realize that these are common errors in human thinking, not just in assessments made by psychologists. As you study abnormal psychology, you probably pay more attention to information that is consistent with your own ideas and are overly influenced by dramatic case studies. Critical thinking—careful, objective reasoning and evaluation—is the best safeguard against these tendencies for you and for professional psychologists.

classification and assessment of abnormal behavior CHAPTER 4 93

he experienced at school were the central features of his prob- lem. His obsessive thoughts of contamination were private events that could only be known to the psychologist on the basis of Michael’s self-report, which was quite compelling. His family could observe Michael’s peculiar habits with regard to arranging his schoolbooks, changing his clothes, and washing his hands, but the significance of these behaviors to Michael was not imme- diately apparent without the knowledge that they were based on an attempt to control or neutralize his anxiety-provoking images of taunting classmates.

Interviews also allow clinicians to observe important features of a person’s appearance and nonverbal behavior. In Michael’s case, the psychologist noticed during the initial interview that the skin on Michael’s hands and lower arms was red and chafed from excessive scrubbing. He was neatly dressed but seemed espe- cially self-conscious about his hair and glasses, which he adjusted repeatedly. Michael was reluctant to make eye contact, and his speech was soft and hesitant. His obvious discomfort in this social situation was consistent with his own descriptions of the anxiety that he felt during interactions with peers. It was also interesting to note that Michael became visibly agitated when discussing par- ticular subjects, such as the incident with his track team. At these points in the interview, he would fidget restlessly in his seat and clasp his arms closely around his sides. These nonverbal aspects of Michael’s behavior provided useful information about the nature of his distress.

STRUCTURED INTERVIEWS Assessment interviews vary with regard to the amount of structure that is imposed by the clini- cian. Some are relatively open-ended, or nondirective. In this type of interview, the clinician follows the train of thought sup- plied by the client. One goal of nondirective interviews is to help people clarify their subjective feelings and to provide general em- pathic support for whatever they may decide to do about their problems. In contrast to this open-ended style, some interviews

follow a more specific question-and-answer format. Structured interviews, in which the clinician must ask each patient a specific list of detailed questions, are frequently employed for collecting information that will be used to make diagnostic decisions and to rate the extent to which a person is impaired by psychopathology.

Several different structured interviews have been developed for the purpose of making psychiatric diagnoses in large-scale epi- demiological and cross-national studies (Segal et al., 2010). Inves- tigators reasoned that the reliability of their diagnostic decisions would improve if they could ensure that clinicians always made a consistent effort to ask the same questions when they interviewed patients. Other forms of structured diagnostic interviews have been designed for use in the diagnosis of specific types of prob- lems, such as personality disorders, anxiety disorders, dissociative disorders, and the behavior problems of children.

Structured interviews list a series of specific questions that lead to a detailed description of the person’s behavior and experiences. As an example, consider the Structured Interview for DSM-IV Personality Disorders (SIDP-IV; Pfohl, Blum, & Zimmerman, 1995), which could have been used as part of the assessment process in Michael’s situation. The SIDP-IV is a widely used interview that covers all of the personality disorder categories. Selected questions from the SIDP-IV are presented in Table 4.2. We have included in this table some of the ques- tions that are specifically relevant to a diagnosis of schizotypal personality disorder.

Structured interview schedules provide a systematic frame- work for the collection of important diagnostic information, but they don’t eliminate the need for an experienced clinician. If the interviewer is not able to establish a comfortable rapport with the client, then the interview might not elicit useful informa- tion. Furthermore, it is difficult to specify in advance all the ques- tions that should be asked in a diagnostic interview. The client’s responses to questions may require clarification. The interviewer must determine when it is necessary to probe further and in what ways to probe. Having lists of specific questions and clear defini- tions of diagnostic criteria will make the clinician’s job easier, but clinical judgment remains an important ingredient in the diag- nostic interview.

ADVANTAGES The clinical interview is the primary tool em- ployed by clinical psychologists in the assessment of psychopa- thology. Several features of interviews account for this popularity, including the following issues:

1. The interviewer can control the interaction and can probe further when necessary.

2. By observing the patient’s nonverbal behavior, the inter- viewer can try to detect areas of resistance. In that sense, the validity of the information may be enhanced.

3. An interview can provide a lot of information in a short period of time. It can cover past events and many different settings.

MyPsychLab VIDEO CASE

Depression/Deliberate Self-Harm

SARAH

“I would be asked later ‘well how did these cuts get here’ and I would know that I had done it, but I wouldn’t remem- ber how I had done it or with what.”

Watch the Video Sarah: Depression/ Deliberate Self-Harm on MyPsychLab

Notice how the interviewer uses a flexible sequence of questions to elicit a compelling description of the subjective experiences associated with Sarah’s cutting behavior.

94 CHAPTER 4 classification and assessment of abnormal behavior

LIMITATIONS Several limitations in the use of clinical interviews as part of the assessment process must be kept in mind. These include the following considerations:

1. Some patients may be unable or unwilling to provide a ratio- nal account of their problems. This may be particularly true of young children, who have not developed verbal skills, as well as some psychotic and demented patients who are un- able to speak coherently.

2. People may be reluctant to admit experiences that are embar- rassing or frightening. They may feel that they should report to the interviewer only those feelings and behaviors that are socially desirable.

3. Information provided by the client is necessarily filtered through the client’s eyes. It is a subjective account and may be influenced or distorted by errors in memory and by selec- tive perception.

4. Interviewers can influence their clients’ accounts by the ways in which they phrase their questions and respond to the cli- ents’ responses.

Observational Procedures In addition to the information that we gain from what people are willing to tell us during interviews, we can also learn a lot by watching their behavior. Observational skills play an important part in most assessment procedures. Sometimes the things that we observe confirm the person’s self-report, and at other times the person’s overt behavior appears to be at odds with what he or she says. A juvenile delinquent might express in words his regret at having injured a classmate, but his smile and the twinkle in his eye may raise doubts about the sincerity of his statement. In situations such as this, we must reconcile information that is obtained from different sources. The picture that emerges of another person’s ad- justment is greatly enriched when data collected from interviews are supplemented by observations of the person’s behavior.

Observational procedures may be either informal or formal. Informal observations are primarily qualitative. The clinician observes the person’s behavior and the environment in which it occurs without attempting to record the frequency or intensity of specific responses. Michael’s case illustrates the value of infor- mal observations in the natural environment. When the therapist

TABLE 4.2 Sample Interview Questions for the Assessment of Schizotypal Personality Disorder Social Relationships

This set of questions concerns the way you think and act in situations that involve other people. Remember that I’m interested in the way you are when you are your usual self.

DSM Diagnostic Criterion: Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

Question: “Do you generally feel nervous or anxious around people?”

(IF YES, ask follow-up questions): “How bad does it get?” “Do you get nervous around people because you worry about what they might be up to?” “Are you less nervous after you get to know people better?”

Perception of Others

The questions in this section ask about experiences you may have had with other people.

DSM Diagnostic Criterion: Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her

Question: “Have you had experiences where people who pretended to be your friends took advantage of you?”

(IF YES, follow-up questions): “What happened?” “How often has this happened?”

Question: “Are you good at spotting someone who is trying to deceive or con you?”

(IF YES, follow-up questions): “Can you give me some examples?”

DSM Diagnostic Criterion: Ideas of reference (the belief that irrelevant or harmless events refer to the person directly or have special personal significance for him or her)

Question: “Have you ever found that people around you seem to be talking in general, but then you realize their comments are really meant for you?”

(IF YES, follow-up question): “How do you know they’re talking about you?”

Question: “Have you felt like someone in charge changed the rules specifically because of you, but they wouldn’t admit it?”

Question: “Do you sometimes feel like strangers on the street are looking at you and talking about you?”

(IF YES, follow-up question): “Why do you think they notice you in particular?”

Source: Bruce, M.D. Pfohl, Nancee Blum and Mark Zimmerman. 1997. Structured Interview for DSM-IV Personality. American Psychiatric Association. Reprinted with permission from the Structured Interview for DSM-IV; Personality (SIDP-IV) (Copyright © 1997). American Psychiatric Association. All Rights Reserved.

Note: The DSM-5 diagnostic criteria for types of personality disorders are identical to those in DSM-IV.

classification and assessment of abnormal behavior CHAPTER 4 95

visited Michael and his parents at their home, he learned that his ritualistic behaviors were more extreme than Michael had origi- nally described. This was useful, but not particularly surprising, as patients with OCD are often reluctant to describe in an inter- view the full extent of their compulsive behavior. The therapist also learned that the parents themselves were quite concerned with rules and order. Everything in their home was highly pol- ished and in its place. This observation helped the therapist un- derstand the extent to which Michael’s parents might contribute to, or reinforce, his rigid adherence to a strict set of rules.

Although observations are often conducted in the natural environment, there are times when it is useful to observe the per- son’s behavior in a situation that the psychologist can arrange and control. Sometimes it isn’t possible to observe the person’s behav- ior in the natural environment because the behavior in question occurs infrequently or at times when an observer cannot be pres- ent; at other times the environment is inaccessible; and some- times the behavior that is of interest is inherently a private act. In these cases, the psychologist may arrange to observe the person’s behavior in a situation that in some ways approximates the real

environment. These artificial situations may also allow for more careful measurements of the person’s problem than could be ac- complished in a more complex situation.

In the case of obsessive–compulsive behavior, this approach might involve asking the person deliberately to touch an object that would ordinarily trigger ritualistic behaviors. The therapist might collect a set of objects that Michael would not want to touch, such as a schoolbook, a pair of old track shorts, and the knob of a door leading to the laundry room. It would be useful to know specifically which objects he would touch, the degree of discomfort that he experienced when touching them, and the length of time that he was able to wait before washing his hands after touching these objects. This information could also be used as an index of change as treatment progressed.

RATING SCALES Various types of procedures can be used to pro- vide quantitative assessments of a person’s behavior that are based on observations. One alternative is to use a rating scale in which the observer is asked to make judgments that place the person some- where along a dimension. For example, a clinician might observe a person’s behavior for an extended period of time and then com- plete a set of ratings that are concerned with dimensions such as the extent to which the person exhibits compulsive ritualistic behaviors.

Ratings can also be made on the basis of information col- lected during an interview. The Yale-Brown Obsessive Compul- sive Scale (Y-BOCS; Goodman et al., 1989; Woody, Steketee, & Chambless, 1995) is an example of an interview-based rating scale that is used extensively in the evaluation of people with problems like Michael’s. The interviewer asks the person a series of specific questions about the nature of his or her experience with obsessive thoughts and compulsive behaviors. For example, “How much of your time is occupied by obsessive thoughts?” Using a scale that ranges from 0 (none) to 4 (extreme), the interviewer then as- signs a rating on several dimensions such as “time spent occupied by obsessive thoughts,” “interference due to obsessive thoughts,” “distress associated with obsessive thoughts,” and “resistance against obsessions.” The composite rating—the total across all the items in the scale—can be used as an index of the severity of the disorder.

Rating scales provide abstract descriptions of a person’s be- havior rather than a specific record of exactly what the person has done. They require social judgments on the part of the observer, who must compare this person’s behavior with an ideal view of other people. How does this person compare to someone who has never experienced any difficulties in this particular area? How does the person compare to the most severely disturbed patients? The value of these judgments depends on the experience of the person who makes the ratings. They are useful to the extent that the observer is able to synthesize accurately the information that has been collected and then rate the frequency or severity of the problem relative to the behavior of other people.

Direct observation can provide one of the most useful sources of information about a person’s behavior. In this case, the children and their teacher are being observed from behind a one-way mirror in order to minimize reactivity, the effect that the observer’s presence might have on their behavior.

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BEHAVIORAL CODING SYSTEMS Another approach to quanti- fying observational data depends on recording the person’s actual activities. Rather than making judgments about where the person falls on a particular dimension, behavioral coding systems focus on the frequency of specific behavioral events (Furr & Funder, 2007). This type of observation, therefore, requires fewer infer- ences on the part of the observer. Because they require extensive time and training, behavioral coding systems are used more fre- quently in research studies than in clinical settings. Coding sys- tems can be used with observations that are made in the person’s natural environment as well as with those that are performed in artificial, or contrived, situations that are specifically designed to elicit the problem behavior under circumstances in which it can be observed precisely. In some cases, the observations are made directly by a therapist, and at other times the information is pro- vided by people who have a better opportunity to see the person’s behavior in the natural environment, including teachers, parents, spouse, and peers.

Some approaches to systematic observation can be relatively simple. Consider, once again, the case of Michael. After the psy- chologist had conducted several interviews with Michael and his family, he asked Michael’s mother to participate in the assessment process by making detailed observations of his hand washing over a period of several nights. The mother was given a set of forms— one for each day—that could be used to record each incident, the time at which it occurred, and the circumstances that preceded the washing. The day was divided into 30-minute intervals start- ing at 6:30 a.m., when Michael got out of bed, and ending at 10:30 p.m., when he usually went to sleep. On each line (one for each time interval), his mother indicated whether he had washed his hands, what had been going on just prior to washing, and how anxious (on a scale from 1 to 100) Michael felt at the time that he washed.

Some adult clients are able to complete this kind of record by keeping track of their own behavior—a procedure known as self- monitoring. In this case, Michael’s mother was asked to help be- cause she was considered a more accurate observer than Michael and because Michael did not want to touch the form that would be used to record these observations. He believed that it was con- taminated because it had touched his school clothes, which he wore to the therapy session.

Two weeks of observations were examined prior to the start of Michael’s treatment. They indicated several things, in- cluding the times of the day when Michael was most active with his washing rituals (between 6 and 9 p.m.) and those spe- cific objects and areas in the house that were most likely to trigger a washing incident. This information helped the thera- pist plan the treatment procedure, which would depend on ap- proaching Michael’s problem at the level that could most easily be handled and moving toward those situations that were the most difficult for him. The observations provided by Michael’s mother were also used to mark his progress after treatment began.

ADVANTAGES Observational measures, including rating scales and behavioral coding systems, can provide a useful supplement to information that is typically collected in an interview format. Their advantage lies primarily in the fact that clinicians observe behavior directly rather than relying on patients’ self-reports. Spe- cific types of observational measures have distinct advantages:

1. Rating scales are primarily useful as an overall index of symp- tom severity or functional impairment.

2. Behavioral coding systems provide detailed information about the person’s behavior in a particular situation.

LIMITATIONS Observations are sometimes considered to be similar to photographs: They provide a more direct or realistic view of behavior than do people’s recollections of their actions and feelings. But just as the quality of a photograph is influenced by the quality of the camera, the value of observational data depends on the procedures that are used to collect them. Thus, observations have a number of limitations:

1. Observational procedures can be time-consuming and there- fore expensive. Raters usually require extensive training before they can use a detailed behavioral coding system.

2. Observers can make errors. Their perception may be biased, just as the inferences of an interviewer may be biased. The reliability of ratings as well as behavioral coding must be monitored.

3. People may alter their behavior, either intentionally or unin- tentionally, when they know that they are being observed— a phenomenon known as reactivity. For example, a person who is asked to count the number of times that he washes his hands may wash less frequently than he does when he is not keeping track.

4. Observational measures tell us only about the particular situ- ation that was selected to be observed. We don’t know if the person will behave in a similar way elsewhere or at a different time, unless we extend the scope of our observations.

5. There are some aspects of psychopathology that cannot be observed by anyone other than the person who has the prob- lem. This is especially true for subjective experiences, such as guilt or low self-esteem.

Personality Tests and Self-Report Inventories Personality tests are another important source of information about an individual’s adjustment. Tests provide an opportunity to collect samples of a person’s behavior in a standardized situ- ation. The person who is being tested is presented with some kind of standard stimuli, usually specific questions that can be answered true or false. Exactly the same stimuli are used every time that the test is given. In that way, the clinician can be sure that differences in performance can be interpreted as differ- ences in abilities or traits rather than differences in the testing situation.

classification and assessment of abnormal behavior CHAPTER 4 97

Personality inventories consist of a series of straightforward statements; the person being tested is typically required to indi- cate whether each statement is true or false in relation to him- self or herself. Several types of personality inventories are widely used. Some are designed to identify personality traits in a normal population, and others focus more specifically on psychological problems. We have chosen to focus on the most extensively used personality inventory—the Minnesota Multiphasic Personality In- ventory (MMPI)—to illustrate the characteristics of these tests as assessment devices.

The original version of the MMPI was developed in the 1940s at the University of Minnesota. For the past 60 years, it has been the most widely used psychological test. Thousands of research articles have been published on the MMPI. The inven- tory was revised several years ago, and it is currently known as the MMPI-2 (Butcher, 2006).

The MMPI-2 is based on a series of more than 500 state- ments that cover topics ranging from physical complaints and psychological states to occupational preferences and social atti- tudes. Examples are statements such as, “I sometimes keep on at a thing until others lose their patience with me”; “My feelings are easily hurt”; and “There are persons who are trying to steal my thoughts and ideas.” After reading each statement, the person is instructed to indicate whether it is true or false. Scoring of the MMPI-2 is objective. After the responses to all questions are to- taled, the person receives a numerical score on each of 10 clinical scales as well as four validity scales.

Before considering the possible clinical significance of a per- son’s MMPI-2 profile, the psychologist will examine a number of validity scales, which reflect the patient’s attitude toward the test and the openness and consistency with which the questions were answered. The L (Lie) Scale is sensitive to unsophisticated attempts to avoid answering in a frank and honest manner. For example, one statement on this scale says, “At times I feel like

swearing.” Although this is perhaps not an admirable trait, vir- tually all normal subjects indicate that the item is true. Subjects who indicate that the item is false (does not apply to them) re- ceive 1 point on the L scale.

Several responses of this sort would result in an elevated score on the scale and would indicate that the person’s overall test re- sults should not be interpreted as a true reflection of his or her feelings. Other validity scales reflect tendencies to exaggerate problems, carelessness in completing the questions, and unusual defensiveness.

If the profile is considered valid, the process of interpreta- tion will be directed toward the 10 clinical scales, which are de- scribed in Table 4.3. Some of these scales carry rather obvious meaning, whereas others are associated with a more general or mixed pattern of symptoms. For example, Scale 2 (Depression) is a relatively straightforward index of degree of depression. Scale 7 (Psychasthenia), in contrast, is more complex and is based on items that measure anxiety, insecurity, and excessive doubt. There are many different ways to obtain an elevated score on any of the clinical scales, because each scale is composed of many items. Even the more obvious scales can indicate several different types of problems. Therefore, the pattern of scale scores is more impor- tant than the elevation of any particular scale.

Rather than depending only on their own experience and clinical judgment, which may be subject to various sorts of bias and inconsistency, many clinicians analyze the results of a specific test on the basis of an explicit set of rules that are derived from empirical research (Greene, 2006). This is known as an actuarial interpretation. We can illustrate this process using Michael’s profile. The profile is first described in terms of the pattern of scale scores, beginning with the highest and proceeding to the lowest. Those that are elevated above a scale score of 70 are most important, and interpretations are sometimes based on the “high- point pair.”

TABLE 4.3 Clinical Scales for the MMPI-2 Scale Number Scale Name Interpretation of High Scores

1 Hypochondriasis Excessive bodily concern; somatic symptoms

2 Depression Depressed; pessimistic; irritable; demanding

3 Hysteria Physical symptoms that cannot be traced to a medical illness; self-centered; demands attention

4 Psychopathic Deviate Asocial or antisocial; rebellious; impulsive, poor judgment

5 Masculinity- Femininity

For men: aesthetic interests For women: assertive; competitive; self-confident

6 Paranoia Suspicious, sensitive; resentful; rigid; may be frankly psychotic

7 Psychasthenia Anxious; worried; obsessive; lacks self-confidence; problems in decision making

8 Schizophrenia May have thinking disturbance, withdrawn; feels alienated and unaccepted

9 Hypomania Excessive activity; lacks direction; low frustration tolerance; friendly

0 Social-Introversion Socially introverted; shy; sensitive; overcontrolled; conforming

98 CHAPTER 4 classification and assessment of abnormal behavior

Following this procedure, Michael’s profile could be coded as a 2–0; that is, his highest scores were on Scales 2 and 0. The clini- cian then looks up this specific configuration of scores in a kind of MMPI-2 “cookbook” to see what sort of descriptive character- istics apply. One cookbook offers the following statement about adolescents (mostly 14 and 15 years old) who fit the 2–0/0–2 code type:

Eighty-seven percent of the 2–0/0–2s express feelings of in- feriority to their therapists. They say that they are not good- looking, that they are afraid to speak up in class, and that they feel awkward when they meet people or try to make a date (91 percent of high 2–0/0–2s). Their therapists see the 2–0/0–2s as anxious, fearful, timid, withdrawn, and inhib- ited. They are depressed, and very vulnerable to threat. The 2–0/0–2 adolescents are overcontrolled; they cannot let go, even when it would be appropriate for them to do so. They are afraid of emotional involvement with others and, in fact, seem to have little need for such affiliation. These adoles- cents are viewed by their psychotherapists as schizoid; they think and associate in unusual ways and spend a good deal of time in personal fantasy and daydreaming. They are serious young people who tend to anticipate problems and difficul- ties. Indeed, they are prone toward obsessional thinking and are compulsively meticulous.

(Marks, Seeman, & Haller, 1974, p. 201)

Several comments must be made about this statement. First, nothing is certain. Actuarial descriptions are probabil- ity statements. They indicate that a certain proportion of the people who produce this pattern of scores will be associated with a certain characteristic or behavior. If 87 percent of the

adolescents who produce this code type express feelings of infe- riority, 13 percent do not. Many aspects of this description ap- ply to Michael’s current adjustment, but they don’t all fit. The MMPI-2 must be used in conjunction with other assessment procedures. The accuracy of actuarial statements can be verified through interviews with the person or through direct observa- tions of his or her behavior.

ADVANTAGES The MMPI-2 has several advantages in compari- son to interviews and observational procedures. In clinical prac- tice, it is seldom used by itself, but, for the following reasons, it can serve as a useful supplement to other methods of collecting information.

1. The MMPI-2 provides information about the person’s test- taking attitude, which alerts the clinician to the possibil- ity that clients are careless, defensive, or exaggerating their problems.

2. The MMPI-2 covers a wide range of problems in a direct and efficient manner. It would take a clinician several hours to go over all these topics using an interview format.

3. Because the MMPI-2 is scored objectively, the test’s descrip- tion of the person’s adjustment is not influenced by the clini- cian’s subjective impression of the client.

4. The MMPI-2 can be interpreted in an actuarial fashion, us- ing extensive banks of information regarding people who re- spond to items in a particular way.

LIMITATIONS The MMPI-2 also has some limitations. Some of its limitations derive from the fact that it has been used for many years, and the ways in which different forms of psychopathology are viewed have changed over time.

1. The utility of the traditional clinical scales (see Table 4.3) has been questioned, especially with regard to their ability to discriminate between different types of mental disorders. Restructured clinical scales have been developed in order to address these problems, but the new scales remain controver- sial (Nichols, 2006).

2. The test depends on the person’s ability to read and respond to written statements. Some people cannot complete the rather extensive list of questions. These include many people who are acutely psychotic, intellectually impaired, or poorly educated.

3. Specific data are not always available for a particular profile. Many patients’ test results do not meet criteria for a particu- lar code type with which extensive data are associated. There- fore, actuarial interpretation is not really possible for these profiles.

4. Some studies have found that profile types are not stable over time. It is not clear whether this instability should be inter- preted as lack of reliability or as sensitivity to change in the person’s level of adjustment.© Michael Maslin/The New Yorker Collection/www.cartoonbank.com

classification and assessment of abnormal behavior CHAPTER 4 99

Projective Personality Tests In projective tests, the person is presented with a series of am- biguous stimuli. The best known projective test, introduced in 1921 by Hermann Rorschach (1884–1922), a Swiss psychiatrist, is based on the use of inkblots. The Rorschach test consists of a series of 10 inkblots. Five contain various shades of gray on a white background, and five contain elements of color. The person is asked to look at each card and indicate what it looks like or what it appears to be. There are, of course, no correct answers. The instructions are intentionally vague in order to avoid influ- encing the person’s responses through subtle suggestions.

Projective techniques such as the Rorschach test were origi- nally based on psychodynamic assumptions about the nature of personality and psychopathology. Considerable emphasis was placed on the importance of unconscious motivations—conflicts and impulses of which the person is largely unaware. In other words, people being tested presumably project hidden desires and conflicts when they try to describe or explain the cards. In so do- ing, they may reveal things about themselves of which they are not consciously aware or that they might not be willing to admit if they were asked directly. The cards are not designed or cho- sen to be realistic or representational; they presumably look like whatever the person wants them to look like.

Michael did not actually complete any projective person- ality tests. We can illustrate the way in which these tests might have been used in his case, however, by considering a man who had been given a diagnosis of obsessive–compulsive disorder as well as showing evidence of two types of personality disor- ders—dependent and schizotypal features. This patient was 22 years old, unemployed, and living with his mother. His father had died in an accident four years earlier. Like Michael, this man was bothered by intrusive thoughts of contamination, and he frequently engaged in compulsive washing (Hurt, Reznikoff, & Clarkin, 1991). His responses to the cards on the Rorschach

frequently mentioned emotional distress (“a man screaming”), in- terpersonal conflict (“two women fighting over something”), and war (“two mushrooms of a nuclear bomb cloud”). He did not incorporate color into any of his responses to the cards.

The original procedures for scoring the Rorschach were largely impressionistic and placed considerable emphasis on the content of the person’s response. Responses given in the example above might be taken to suggest a number of important themes. Aggression and violence are obvious possibilities. Perhaps the man was repressing feelings of hostility, as indicated by his frequent references to war and conflict. These themes were coupled with a guarded approach to emotional reactions, which is presumably reflected by his avoidance of color. The psychologist might have wondered whether the man felt guilty about something, such as his father’s death. This kind of interpretation, which depends heavily on symbolism and clinical inference, provides intriguing material for the clinician to puzzle over. Unfortunately, the reli- ability and validity of this intuitive type of scoring procedure are very low (Garb et al., 2005).

When we ponder the utility of these interpretations, we should also keep in mind the relative efficiency of projective test- ing procedures. Did the test tell us anything that we didn’t already know or that we couldn’t have learned in a more straightforward manner? The clinician might learn about a client’s feelings of an- ger or guilt by using a clinical interview, which is often a more direct and efficient way of collecting information.

More recent approaches to the use of projective tests view the person’s descriptions of the cards as a sample of his or her percep- tual and cognitive styles (Meyer & Viglione, 2008). The Compre- hensive System, an objective scoring procedure for the Rorschach, is based primarily on the form rather than the content of the sub- ject’s responses. According to this system, interpretation of the test depends on the way in which the descriptions take into account the shapes and colors on the cards. Does the person see movement in the card? Does she focus on tiny details, or does she base her de- scriptions on global impressions of the entire form of the inkblot? These and many other considerations contribute to the overall in- terpretation of the Rorschach test. The reliability of this scoring system is much better than would be achieved by informal, im- pressionistic procedures. Research evidence supports the validity of some of these scales, especially those concerned with cognitive and perceptual processes (Mihura et al., 2013), but the validity of other scores remains open to question (Wood et al., 2003).

There are many different types of projective tests. Some em- ploy stimuli that are somewhat less ambiguous than the inkblots in the Rorschach. The Thematic Apperception Test (TAT), for example, consists of a series of drawings that depict human fig- ures in various ambiguous situations. Most of the cards portray more than one person. The figures and their poses tend to elicit stories with themes of sadness and violence. The person is asked to describe the identities of the people in the cards and to make up a story about what is happening. These stories presumably re- flect the person’s own ways of perceiving reality.

Projective tests require a person to respond to ambiguous stimuli. Here, a woman is taking the Thematic Apperception Test (TAT), in which she will be asked to make up a story about a series of drawings of people.

100 CHAPTER 4 classification and assessment of abnormal behavior

ADVANTAGES The advantages of projective tests center on the fact that the tests are interesting to give and interpret, and they sometimes provide a way to talk to people who are otherwise re- luctant or unable to discuss their problems. Projective tests are more appealing to psychologists who adopt a psychodynamic view of personality and psychopathology because such tests are believed to reflect unconscious conflicts and motivations. Some specific advantages are listed as follows:

1. Some people may feel more comfortable talking in an unstruc- tured situation than they would if they were required to partici- pate in a structured interview or to complete the lengthy MMPI.

2. Projective tests can provide an interesting source of informa- tion regarding the person’s unique view of the world, and they can be a useful supplement to information obtained with other assessment tools (Weiner & Meyer, 2009).

3. To whatever extent a person’s relationships with other people are governed by unconscious cognitive and emotional events, projective tests may provide information that cannot be ob- tained through direct interviewing methods or observational procedures (Meyer & Archer, 2001; Stricker & Gold, 1999).

LIMITATIONS There are many serious problems with the use of projective tests. The popularity of projective tests has declined considerably since the 1970s, even in clinical settings, primarily because research studies have found relatively little evidence to support their reliability and validity (Garb et al., 2005).

1. Lack of standardization in administration and scoring was a serious problem, but the Comprehensive System for scoring the Rorschach has made improvements in that regard.

2. Little information is available on which to base comparisons to normal adults or children.

3. Some projective procedures, such as the Rorschach, can be very time consuming, particularly if the person’s responses are scored with a standardized procedure such as the Com- prehensive System.

4. Information regarding the reliability and validity of projective tests is mixed, with many scales showing little systematic value.

Biological Assessment Procedures Clinicians have developed a number of techniques for measuring the association between biological systems and abnormal behav- ior. These techniques are seldom used in clinical practice (at least for the diagnosis of psychopathology), but they have been em- ployed extensively in research settings, and it seems possible that they will one day become an important source of information on individual patients.

Brain Imaging Techniques The past three decades have seen a tremendous explosion of in- formation and technology in the neurosciences. We now under- stand in considerable detail how neurons in the central nervous system communicate with one another, and scientists have in- vented sophisticated methods to create images of the living hu- man brain (Bremner, 2005; Lagopoulos, 2010). Some of these procedures provide static pictures of various brain structures at rest, just as an X-ray provides a photographic image of a bone

Positron emission tomogra- phy (PET scan) can provide useful images of dynamic brain functions. Areas that appear red or yellow indicate areas of the brain that are active (consuming the labeled glucose molecules), whereas those that are blue or green are relatively inactive. Different areas of the brain become active depending on whether the person is at rest or en- gaged in particular activities when the image is created.

classification and assessment of abnormal behavior CHAPTER 4 101

or some other organ of the body. Studies of this type are typi- cally concerned with the size of various parts of the brain. For example, many studies have compared the average size of the lat- eral ventricles—large chambers filled with cerebrospinal fluid— in groups of patients with schizophrenia and normal comparison groups. Other methods can be used to create dynamic images of brain functions—reflecting the rate of activity in various parts of the brain—while a person is performing different tasks. These functional images allow scientists to examine which parts of the brain are involved in various kinds of events, such as perception, memory, language, and emotional experience. They may also al- low us to learn whether specific areas or pathways in the brain are uniquely associated with specific types of mental disorders.

Precise measures of brain structure can be obtained with magnetic resonance imaging (MRI). In MRI, images are generated using a strong magnetic field rather than X-rays (Posner & Di- Girolamo, 2000). A large magnet in the scanner causes chemical elements in specific brain regions to emit distinctive radio sig- nals. Both computed tomography (CT) scanning and MRI can provide a static image of specific brain structures. MRI provides more detailed images than CT scans and is able to identify smaller parts of the brain. For this reason, and because it lends itself more easily to the creation of three-dimensional pictures of the brain, MRI has replaced CT scanning in most research facilities.

In addition to structural MRI, which provides a static view of brain structures, advances in the neurosciences have also pro- duced techniques that create images of brain functions (Brown & Thompson, 2010; Raichle, 2005). Positron emission tomography (PET) is one scanning technique that can be used to create func- tional brain images (Wahl, 2002). This procedure is much more expensive than the other imaging techniques because it requires a nuclear cyclotron to produce special radioactive elements. PET scans are capable of providing relatively detailed images of the brain. In addition, they can reflect changes in brain activity as the person responds to the demands of various tasks.

The newest and most exciting method of imaging brain functions involves functional MRI (fMRI). When neurons are activated, their metabolism increases and they require increased blood flow to supply them with oxygen. The magnetic properties of blood change as a function of the level of oxygen that it is car- rying. In fMRI, a series of images is acquired in rapid succession. Small differences in signal intensity from one image to the next provide a measure of moment-to-moment changes in the amount of oxygen in blood flowing to specific areas of the brain. While other functional imaging procedures such as PET are only able to measure activities that are sustained over a period of several min- utes, fMRI is able to identify changes in brain activity that lasts less than a second (Huettel, Song, & McCarthy, 2004).

Functional brain imaging procedures have been used exten- sively to study possible neurological underpinnings of various types of mental disorders. For example, in the case of obsessive-compul- sive disorder (OCD), studies using PET and fMRI have suggested that symptoms of OCD are associated with multiple brain regions,

including the caudate nucleus, the orbital prefrontal cortex, and the anterior cingulate cortex (located on the medial surface of the frontal lobe). These pathways are illustrated in Figure 4.2. They seem to be overly active in people with OCD, especially when the person is confronted with stimuli that provoke his or her obsessions (Husted, Shapira, & Goodman, 2006; Menzies et al., 2008).

These results are intriguing because they suggest that certain regions and circuits in the brain may somehow be associated with the presence of obsessive–compulsive symptoms. We must em- phasize, however, that the results of such imaging procedures are not useful diagnostically with regard to an individual person. In other words, some people with OCD do not exhibit increased metabolism rates in the caudate or the anterior cingulate cortex, and some people who do not have OCD do show increased levels of activity in these brain regions.

ADVANTAGES Brain imaging techniques provide detailed infor- mation regarding the structure of brain areas and activity levels in the brain that are associated with the performance of particular tasks. They have important uses, primarily as research tools:

1. In clinical practice, imaging techniques can be used to rule out various neurological conditions that might explain be- havioral or cognitive deficits. These include such conditions as brain tumors and vascular disease.

2. Procedures such as fMRI and PET can help research inves- tigators explore the relation between brain functions and specific mental disorders. This type of information will be considered in several chapters later in this book.

FIGURE 4.2 Brain Regions Associated with OCD When a person with OCD experiences symptoms, an increase in neural activity is seen in the caudate (A), which triggers the urge to “do something,” through the orbital prefrontal cortex (B), which gives the feeling that “something is wrong,” and back through the anterior cingulated cortex (C), which keeps attention fixed on the feeling of unease.

(A) Head of Caudate Nucleus

Tail of Caudate Nucleus

Putamen

Amygdala

(B) Orbital Prefrontal Cortex

(C) Anterior Cingulate Cortex

102 CHAPTER 4 classification and assessment of abnormal behavior

LIMITATIONS Brain imaging procedures are used extensively in the study and assessment of neurological disorders. In the field of psychopathology, they are currently research tools and have little clinical importance outside the assessment and treatment of dis- orders such as Alzheimer’s disease (see Chapter 14). Some of the major limitations are listed here:

1. Norms have not been established for any of these measures. It is not possible to use brain imaging procedures for diag- nostic purposes.

2. These procedures are relatively expensive—especially PET scans and fMRI—and some procedures must be used cau- tiously because the patient may be exposed to radioactive substances.

3. We should not assume that all cognitive processes, emotional experiences, or mental disorders are necessarily linked to activity (or the absence of activity) in a specific area of the brain. Scientists are still debating the extent to which these experiences are localized within the brain (Uttal, 2001).

This view of Earth from space shows hot spots on the Earth’s surface at night, an indication of areas of heavier population. Imaging techniques like fMRI offer views of the brain that are similarly fascinating—and similarly lacking in resolution, detail, and meaning.

getting HELP

Only one in five people who need treatment actually gets it. There are several reasons for this unfortunate state of events. One is lack of information. If you don’t recognize the presence of a serious problem, you won’t seek help. You will get care more promptly and make better treatment choices if you understand your problems. One consideration is the extent to which your experiences resemble the formal diagnostic terms used by mental health professionals. Allen Frances and Michael First have written a useful book called Your Mental Health: A Layman’s Guide to the Psychiatrist’s Bible. This primer for consumers of men- tal health services covers many types of adult and childhood disor- ders. Each chapter includes a concise, readable description of the typical symptoms and course of the disorder, followed by a discus- sion designed to help you decide whether your problems warrant professional help (“Am I okay?”). Finally, the authors review treat- ment options and where to go for help for each of the problems.

Even after they recognize the presence of a serious problem, some people are reluctant to seek help; they fear there is a stigma attached to “mental problems” despite the fact that

seeking therapy is now commonplace. Negative stereotypes re- garding mental disorders persist. We hope that you will not allow these distorted views to delay or interfere with efforts to improve your life. If you have concerns about this issue, it may help to read about stigma and mental health, a problem that has been addressed by Rosalynn Carter, a leading advocate on behalf of people with mental disorders and wife of former president Jimmy Carter. Her book, Helping Someone with Mental Illness, contains an excellent discussion of these issues. The Carter Center is ac- tively involved in issues that affect public policies regarding men- tal disorders. The URL for its Web page is www.cartercenter.org. It also contains information relevant to the struggle to correct biased and inaccurate views of people with mental disorders.

We all can help eliminate discrimination against those who suf- fer from (or have recovered from) mental disorders. Advice for positive action is presented on several Web sites, including the National Mental Health America’s home page. People will find it easier to seek help when they no longer need to worry about the potential effects of distorted, negative views of their problems.

classification and assessment of abnormal behavior CHAPTER 4 103

Formal classification systems for mental disorders have been developed in order to facilitate communication, research, and treatment planning. Clinicians assign a diagnosis if the person’s behavior meets the specific criteria for a particular type of disor- der, such as schizophrenia or major depressive disorder.

The current official system published by the American Psychiatric Association is the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5. It is based on a categorical approach to classification and typically employs specific inclu- sion and exclusion criteria to define each disorder. The catego- ries that are defined in DSM-5 are based primarily on descriptive principles rather than on theoretical knowledge regarding the etiology of the disorders.

Scientists may also use a dimensional approach to classification— that is, one that describes the objects of classification in terms of continuous dimensions. In fact, most features of mental disorders, such as anxiety and depressed mood, are dimensional in nature.

Cultural factors play an important role in both the expression and recognition of symptoms of mental disorders. The accuracy and utility of a clinical diagnosis depend on the clinician’s ability to consider the cultural context in which the problem appeared. DSM-5 includes a glossary of cultural concepts of distress, such as ataques de nervios.

The usefulness of a classification system depends on several criteria, especially reliability and validity. The reliability of many

categories in DSM-5 is good, but other disorders are more prob- lematic in this regard. The validity of most categories remains under active investigation.

The general process of collecting and interpreting informa- tion is called assessment. Interviews, observations, and tests are among the most frequently used assessment procedures. It is never possible to learn everything about a particular per- son. Choices have to be made, and some information must be excluded from the analysis.

Structured diagnostic interviews are used extensively in conjunc- tion with the DSM-5 classification system. The main advantage of interviews is their flexibility. Their primary limitation lies in the inability or unwillingness of some clients to provide a rational description of their own problems, as well as the subjective fac- tors that influence the clinician’s interpretation of data collected in an interview.

Personality inventories, like the MMPI-2, offer several advan- tages as assessment devices. They can be scored objectively, they often contain validity scales that reflect the person’s atti- tude and test-taking set, and they can be interpreted in refer- ence to well-established standards for people with and without specific types of adjustment problems.

Some psychologists use projective personality tests, like the Rorschach, to acquire information that might not be obtained from direct interviews or observations. Research studies have found mixed evidence to support the validity of projective tests, and their continued use is controversial.

Biological assessment procedures are used primarily in research studies. These include brain imaging techniques, such as fMRI and PET scans, as well as psychophysiological recording pro- cedures. Biological assessment procedures do not yet have diagnostic value in clinical situations, except for the purpose of ruling out certain conditions, such as brain tumors and vascular disease.

Summary4

4.1 Why do we need a system to classify abnormal behavior? Classification systems provide a way for scientists and clinicians to organize information and communicate with each other and with patients regarding the nature of mental disorders . . . (see page 78).

4.2 Should disorders that are unique to our own culture be con- sidered cultural concepts of distress? In the same way that ataques de nervios is a behavioral phenomenon associated with the culture of Puerto Rico, bulimia seems to be uniquely associated with Western culture and is closely linked to its values regarding beauty . . . (see page 84).

4.3 What is the difference between reliability and validity? The fact that two people agree on assigning a specific diag- nosis does not necessarily imply that it is meaningful . . . (see pages 85–86).

4.4 How could the DSM-5 classification system be improved? Many experts agree that the classification system should pay greater attention to the dimensional nature of abnormal behaviors while attempting to clarify the boundaries between mental disorders and normal behavior . . . (see pages 88–90).

critical thinking review

The Big Picture

104 CHAPTER 4 classification and assessment of abnormal behavior

key terms actuarial

interpretation 97 assessment 78 categorical approach to

classification 80

classification system 80 comorbidity 89 cultural concepts of

distress 84 diagnosis 78

dimensional approach to classification 80

personality inventory 97 projective tests 99 rating scale 95

reactivity 96 reliability 85 stigma 82 validity 86

4.5 Why do clinical interviews sometimes provide limited or distorted results? Some people are either unwilling or unable to provide an accurate account of their problems . . . (see page 94).

4.6 Why is the MMPI-2 sometimes called an objective personality test? The person’s responses to test items are scored according to an explicit set of rules that are based on empirical research and inter- preted using actuarial predictions . . . (see page 97).

4.7 Why are brain imaging procedures not used for the diagnosis of mental disorders? They are currently best seen as research tools. No unique patterns of brain structure or function have been found that consistently and accurately identify people with specific mental disorders . . . (see page 102).

5

mood disorders and suicide

106 CHAPTER 5 mood disorders and suicide

5 The Big Picture learning objectives

5.1 What is the difference between clinical

depression and a low mood?

5.2 Are there different kinds of depression?

5.3 How do depressive and bipolar disorders differ?

5.4 Are we more likely to experience depression as we get older?

5.5 Why do some people become depressed after

stressful life events while others do not?

5.6 Is psychological treatment as effective as

medication in treating depression?

5.7 Why do some people want to end their own lives?

Sadness may be the price that we pay for attachments to other peo- ple. Losses are inevitable, and we all endure the pain that comes with them. Beyond relatively short-lived feelings of grief and sorrow, pro- longed sadness can grow into something much more debilitating. Everyone’s life contains the potential for despair. Some people are able to work their way through it, but others become overwhelmed. When it reaches higher levels of intensity and begins to interfere with a person’s ability to function and enjoy life, a low mood is known as clinical depression. In this chapter we will consider emotional disor- ders that involve prolonged periods of severe depression.

Overview If one measures disability in terms of years lived with severe im- pairments, major depression is the leading cause of disability worldwide (Moussavi et al., 2007). The magnitude of the prob- lem is truly staggering. Depression accounts for almost 10 per- cent of all disability (see Table 5.1). Experts predict that it will become an even greater problem by the year 2020. Younger

generations are experiencing higher rates of depression than their predecessors, and those who become depressed are doing so at an early age.

Psychopathologists use several terms to describe problems that are associated with emotional response systems. This lan- guage can become confusing because most of us already use these words in our everyday vocabulary. Thus, we must define these terms as they are used in psychopathology so that our discussion will be clear. Emotion refers to a state of arousal that is defined by subjective states of feeling, such as sadness, anger, and disgust. Emotions are often accompanied by physiological changes, such as changes in heart rate and respiration rate. Affect refers to the pattern of observable behaviors, such as facial expression, that are associated with these subjective feelings. People also express affect through the pitch of their voices and with their hand and body movements. Mood refers to a pervasive and sustained emotional response that, in its extreme form, can color the person’s percep- tion of the world (APA, 2013). The disorders discussed in this chapter are primarily associated with two specific moods: depres- sion and elation.

Depression can refer either to a mood or to a clinical syn- drome, a combination of emotional, cognitive, and behavioral symptoms. The feelings associated with a depressed mood often include disappointment and despair. Although sadness is a uni- versal experience, profound depression is not. No one has been able to identify the exact point at which “feeling down or blue” crosses a line and becomes depression. One experience shades gradually into the next. The transition has been described by

table 5.1 Leading Causes of Disability Worldwide as Measured by Years of Life Lived with a Disability

All Causes Proportion of Total Years Lived with Disability

1. Depression 9.4

2. Hearing loss 5.5

3. Cataracts 5.2

4. Osteoarthritis 3.2

5. Vision disorders 3.1

6. Cerebrovascular disease 2.7

7. Dementia 2.6

8. Perinatal conditions 2.5

9. Alcohol-use disorders 2.5

10. Chronic obstructive pulmonary disease

2.1

Source: Andrews, Gavin. Depression is very disabling. The Lancet. 2007 September 8; 370(9590).

mood disorders and suicide CHAPTER 5 107

An Attorney’s Major Depressive Episode Cathy was a 31-year-old attorney who had been promoted to the rank of partner the previous year and was considered one of the brightest, most promising young members of her firm. In spite of her apparent success, she was plagued by doubts about her own abilities and was convinced that she was unworthy of her promotion. Cathy decided to seek treatment because she was profoundly miserable. Beyond being depressed, she felt numb. She had been feeling unusually fatigued and irritable for several months, but her mood took a serious swing for the worse after one of the firm’s clients, for whom Cathy was primarily respon- sible, decided to switch to another firm. Although the decision was clearly based on factors that were beyond her control, Cathy blamed herself. She interpreted this event as a reflection of her professional incompetence, in spite of the fact that virtually all of her other clients had praised her work and the senior partners in her firm had given her consistently positive reviews.

Cathy had always looked forward to going to the office, and she truly enjoyed her work. After she lost this client, however, going to work had seemed like an overwhelming burden. She found it impossible to concentrate and instead brooded about her own incompetence. Soon she started calling in sick. She began to spend her time sitting in bed staring at the television screen, without paying attention to any program, and she never left her apartment. She felt lethargic all the time, but she wasn’t sleeping well. Her appetite disappeared. Her best friend tried repeatedly to get in touch with her, but Cathy wouldn’t return her calls. She listened passively as her friend left messages on the answering machine. She just didn’t feel like doing anything or talking to anyone. “Life has lost its interest and meaning. I’ve failed at my job and failed in my relationships. I deserve to be alone.”

Cathy considered her social life to be a disaster, and it didn’t seem to be getting any better. She had been separated from her husband for five years, and her most recent boyfriend had started dating another woman. She had tried desperately for several weeks to force herself to be active, but eventually she stopped caring. The situation seemed completely hopeless. Although she had often gone to parties with other members of her law firm, she usually felt as though she didn’t fit in. Everyone else seemed to be part of a couple, and Cathy was usually on her own. Other people didn’t appreciate the depth of her loneliness. Sometimes it seemed to Cathy that she would be better off dead. She spent a good deal of time brooding about suicide, but she feared that if she tried to harm herself she might make things worse than they already were.

Cathy’s problems would be classified as a depressive disorder because she had experienced at least one episode of major depres- sion and she had never had a manic episode. Her experience pro- vides a framework in which we can discuss the difference between normal sadness and clinical depression.

Andrew Solomon (2001) in The Noonday Demon, an eloquent book in which he documents his own struggles with depression:

Depression starts out insipid, fogs the days into a dull color, weakens ordinary actions until their clear shapes are obscured by the effort they require, leaves you tired and bored and self-obsessed—but you get through all that. Not happily, perhaps, but you can get through. No one has ever been able to define the collapse point that marks ma- jor depression, but when you get there, there’s not much mistaking it. (p. 17)

People who are in a severely depressed mood describe the feeling as overwhelming, suffocating, or numbing. In the syn- drome of depression, which is also called clinical depression, a depressed mood is accompanied by several other symptoms, such as fatigue, loss of energy, difficulty in sleeping, and changes in appetite. Clinical depression also involves a variety of changes in thinking and overt behavior. The person may experience cogni- tive symptoms, such as extreme guilt, feelings of worthlessness, concentration problems, and thoughts of suicide. Behavioral symptoms may range from constant pacing and fidgeting to ex- treme inactivity. Throughout the rest of this chapter, we will use the term depression to refer to the clinical syndrome rather than the mood.

Mania, the flip side of depression, also involves a disturbance in mood that is accompanied by additional symptoms. Euphoria, or elated mood, is the opposite emotional state from a depressed mood. It is characterized by an exaggerated feeling of physical and emotional well-being (APA, 2013). Manic symptoms that fre- quently accompany an elated mood include inflated self-esteem, decreased need for sleep, distractibility, pressure to keep talking, and the subjective feeling of thoughts racing through the person’s head faster than they can be spoken. Mania is, therefore, a syn- drome in the same sense that clinical depression is a syndrome.

Mood disorders are defined in terms of episodes—discrete periods of time in which the person’s behavior is dominated by either a depressed or manic mood. Unfortunately, most people with a mood disorder experience more than one episode. The fol- lowing case studies illustrate the way that numerous symptoms combine to form syndromes that are used to define mood dis- orders. They also provide examples of the two primary types of mood disorders: (1) those in which the person experiences only episodes of depression, known as depressive disorders; and (2) those in which the person experiences episodes of mania as well as depression, known as bipolar disorder. Episodes of de- pression are defined by the same symptoms, regardless of whether the person’s disorder is depressive or bipolar in nature. A small number of patients have only manic episodes with no evidence of depression; they are included in the bipolar category. Years ago, bipolar disorder was known as manic–depressive disorder. Although this term has been replaced in the official diagnostic manual, some clinicians still prefer to use it because it offers a more direct description of the patient’s experience.

108 CHAPTER 5 mood disorders and suicide

Debbie’s manic episode could be traced to experiences that began three or four months prior to her admission to the hospi- tal. Debbie had been feeling unusually good for several weeks. At first she didn’t think anything was wrong. In fact, her impres- sion was quite the opposite. Everything seemed to be going right for her. Her energy level was up, and she felt a renewed confidence in herself and her relationships with other people, es- pecially with her boyfriend, who had recently moved to a distant city. Debbie initially welcomed these feelings, especially because she had been so lethargic and also tended to be reserved with people.

One day when she was feeling particularly exhilarated, Debbie impulsively quit her job and went to visit her boyfriend. Giving up her job without careful consideration and with no prospect for alternative employment was the first indication that Debbie’s judgment was becoming impaired. Although she left home with only enough money to pay for her airplane ticket, she stayed for several weeks, mostly engaged in leisure activities. It was during this time that she started having trouble sleeping. The quality of her mood also began to change. It was often less cheerful and frequently irritable. She was extremely impatient and would become furious if her boyfriend disagreed with her. On one occasion, they had a loud and heated argu- ment in the parking lot of his apartment complex. She took off her blouse and angrily refused to put it on again in spite of his demands and the presence of several interested bystanders. Shortly after the fight, she packed her clothes and hitchhiked back home.

After returning to her parents’ home, Debbie argued with them almost continuously for several days. Her moods shifted constantly. One moment she would be bubbling with enthusiasm, gleefully throwing herself into new and exciting activities. If her plans were thwarted, she would fly into a rage. She phoned an exclusive tennis club to arrange for private lessons, which she ob- viously could not afford, especially now that she was unemployed. Her mother interrupted the call and canceled the lessons. Debbie left the house in a fury and set off to hitch a ride to the tennis

Some important considerations regarding this distinction are listed in Table 5.2. They include the extent to which the low mood remains consistent over an extended period of time as well as the inability to occasionally enjoy activities that would otherwise pro- vide some relief from feeling down or blue. Distractions such as watching television or talking on the phone with a friend had lost their ability to make Cathy feel any better. Her mood had deterio- rated shortly after one of her clients switched to another firm. The intensity of her depression was clearly way out of proportion to the event that seemed to trigger it (departure of a client to another firm). She had withdrawn from other people and was no longer able to work or to participate in any kind of social activity. The onset of her depression was accompanied by a number of other symptoms, including feelings of guilt, lack of energy, and difficulty sleeping. Finally, the quality of her mood was more than just a feel- ing of sadness; she was so profoundly miserable that she felt numb. For all of these reasons, Cathy’s problems would fit the descrip- tion of major depression.

Our next case illustrates the symptoms of mania, which often appear after a person has already experienced at least one episode of depression. People who experience episodes of both depression and mania are given a diagnosis of bipolar disorder. The symp- toms of a full-blown manic episode are not subtle. People who are manic typically have terrible judgment and may get into consid- erable trouble as a result of their disorder. The central feature of mania is a persistently elevated or irritable mood that lasts for at least one week.

Debbie’s Manic Episode Debbie, a 21-year-old single woman, was admitted to a psy- chiatric hospital in the midst of a manic episode. She had been in psychotherapy for depression for several months while she was in high school but had not received any type of treatment since then. After she completed two semesters at a commu- nity college, Debbie found a good-paying job in the advertis- ing office of a local newspaper, where she had been working for two years.

table 5.2 Important Considerations in Distinguishing Clinical Depression from Normal Sadness 1. The mood change is pervasive across situations and persistent over time. The person’s mood does not improve, even temporarily,

when he or she engages in activities that are usually experienced as pleasant.

2. The mood change may occur in the absence of any precipitating events, or it may be completely out of proportion to the person’s circumstances.

3. The depressed mood is accompanied by impaired ability to function in usual social and occupational roles. Even simple activities become overwhelmingly difficult.

4. The change in mood is accompanied by a cluster of additional signs and symptoms, including cognitive, somatic, and behavioral features.

5. The nature or quality of the mood change may be different from that associated with normal sadness. It may feel “strange,” like being engulfed by a black cloud or sunk in a dark hole.

mood disorders and suicide CHAPTER 5 109

dejected, or despondent. The severity of a depressed mood can reach painful and overwhelming proportions. Andrew Solomon (2001) has described the progression from sadness to severe de- pression in the following ways:

I returned, not long ago, to a wood in which I had played as a child and saw an oak, a hundred years dignified, in whose shade I used to play with my brother. In twenty years, a huge vine had attached itself to this confident tree and had nearly smothered it. It was hard to say where the tree left off and the vine began. The vine had twisted itself so en- tirely around the scaffolding of tree branches that its leaves seemed from a distance to be the leaves of the tree; only up close could you see how few living oak branches were left. I empathized with that tree. My depression had grown on me as that vine had conquered the oak; it had been a sucking thing that had wrapped itself around me, ugly and more alive than I. (p. 18)

In contrast to the unpleasant feelings associated with clini- cal depression, manic patients like Debbie experience periods of inexplicable and unbounded joy known as euphoria. Debbie felt extremely optimistic and cheerful—“on top of the world”— in spite of the fact that her inappropriate behavior had made a shambles of her current life circumstances. In bipolar disor- ders, periods of elated mood tend to alternate with phases of depression.

Kay Jamison, professor of psychiatry at Johns Hopkins University School of Medicine, has written an eloquent and moving description of her own experiences with mania and depression.

My manias, at least in their early and mild forms, were ab- solutely intoxicating states that gave rise to great personal pleasure, an incomparable flow of thoughts, and a ceaseless energy that allowed the translation of new ideas into papers and projects. (1995, pp. 5–6)

club. She was picked up by two unknown men, who persuaded her to accompany them to a party rather than go to the club. By the time they arrived at the party, her mood was once again eu- phoric. She stayed at the party all night and had intercourse with three men whom she had never met before.

The following day, Debbie borrowed money from a friend and took a train home. Another argument ensued when she arrived at home. Debbie struck her father and took the family car. Angry and frightened by her apparently irrational behavior, her parents phoned the police, who found her and brought her home. When another argument broke out, even more hostile than the first, the police took Debbie to their precinct office, where she was interviewed by a psychiatrist. Her attitude was flippant, and her language was abusive and obscene. On the basis of her clearly irrational and violent mood, as well as her marked impairment in judgment, the psychiatrist arranged for her to be committed to a psychiatric hospital.

Debbie’s behavior on the ward was belligerent, provocative, and demanding. Although she hadn’t slept a total of more than four hours in the previous three days, she claimed to be bursting with energy. She behaved seductively toward some of the male patients, sitting on their laps, kissing them, and occasionally un- fastening her clothing. Although her speech was coherent, it was rapid and pressured. She expressed several grandiose ideas, in- cluding the boast that she was an Olympic swimmer and that she was a premed student in college. She had no insight into the se- verity of her mental condition. Failing to recognize that her judg- ment was impaired, she insisted that she had been brought to the ward so that she could help the other patients.

“I am a psychic therapist, filled with the healing powers of the universe. I see things so clearly and deeply, and I must share this knowledge with everyone else.”

Symptoms The cases of Cathy and Debbie illustrate many of the most im- portant symptoms and signs of mood disorders, which can be divided into four general areas: emotional symptoms, cognitive symptoms, somatic symptoms, and behavioral symptoms. Episodes of major depression and mania typically involve all four kinds of symptoms.

Emotional Symptoms We all experience negative emotions, such as sadness, fear, and anger. These reactions usually last only a few moments, and they serve a useful purpose in our lives, particularly in our relation- ships with other people. Emotional reactions serve as signals to other people about our current feelings and needs. They also co- ordinate our responses to changes in the immediate environment.

Depressed, or dysphoric (unpleasant), mood is the most common and obvious symptom of depression. Most people who are depressed describe themselves as feeling utterly gloomy,

The quality of a depressed mood is often different from the sadness that might arise from an event such as the loss of a loved one. Some depressed people say that they feel like they are drowning or suffocating.

110 CHAPTER 5 mood disorders and suicide

In contrast to the cognitive slowness associated with depres- sion, manic patients commonly report that their thoughts are speeded up. Ideas flash through their minds faster than they can articulate their thoughts. Manic patients can also be easily dis- tracted, responding to seemingly random stimuli in a completely uninterpretable and incoherent fashion. Grandiosity and inflated self-esteem are also characteristic features of mania.

Many people experience self-destructive ideas and impulses when they are depressed. Interest in suicide usually develops grad- ually and may begin with the vague sense that life is not worth living. Such feelings may follow directly from the overwhelming fatigue and loss of pleasure that typically accompany a seriously depressed mood. In addition, feelings of guilt and failure can lead depressed people to consider killing themselves. Over a period of time, depressed people may come to believe that they would be better off dead or that their family would function more success- fully and happily without them. Preoccupation with such thoughts then leads to specific plans and may culminate in a suicide attempt.

Somatic Symptoms The somatic symptoms of mood disorders are related to basic physiological or bodily functions. They include fatigue, aches and pains, and serious changes in appetite and sleep patterns. People, like Cathy, who are clinically depressed often report feeling tired all the time. The simplest tasks, which she had previously taken for granted, seemed to require an overwhelming effort. Taking a shower, brushing her teeth, and getting dressed in the morning became virtually impossible.

Sleeping problems are also common, particularly trouble get- ting to sleep. This disturbance frequently goes hand in hand with cognitive difficulties mentioned earlier. Worried about her end- less problems and unable to relax, Cathy found that she would toss and turn for hours before finally falling asleep. Some peo- ple also report having difficulty staying asleep throughout the night, and they awaken two or more hours before the usual time.

Unfortunately, as these feelings become more intense and prolonged, they can become ruinous. It may not be clear when the person’s experience crosses the unmarked boundary between being productive and energetic to being out of control and self-destruc- tive. Jamison described this subtle transition in the following way:

There is a particular kind of pain, elation, loneliness, and terror involved in this kind of madness. When you’re high it’s tremendous. The ideas and feelings are fast and frequent like shooting stars, and you follow them until you find bet- ter and brighter ones. Shyness goes, the right words and gestures are suddenly there, the power to captivate others a felt certainty. There are interests found in uninteresting peo- ple. Sensuality is pervasive, and the desire to seduce and be seduced irresistible. Feelings of ease, intensity, power, well- being, financial omnipotence, and euphoria pervade one’s marrow. But, somewhere, this changes. The fast ideas are far too fast, and there are far too many; overwhelming confu- sion replaces clarity. Memory goes. Humor and absorption on friends’ faces are replaced by fear and concern. Every- thing previously moving with the grain is now against— you are irritable, angry, frightened, uncontrollable, and enmeshed totally in the blackest caves of the mind. (p. 67)

Many depressed and manic patients are irritable. Their anger may be directed either at themselves or at others, and frequently at both. Even when they are cheerful, people in a manic epi- sode, like Debbie, are easily provoked to anger. Debbie became extremely argumentative and abusive, particularly when people challenged her grandiose statements about herself and her inap- propriate judgment.

Anxiety is also common among people with mood disorders, just as depression is a common feature of some anxiety disorders (see Chapter 6). People who are depressed are sometimes appre- hensive, fearing that matters will become worse than they already are or that others will discover their inadequacy. They sometimes report that they are chronically tense and unable to relax.

Cognitive Symptoms In addition to changes in the way people feel, mood disorders also involve changes in the way people think about themselves and their surroundings. People who are clinically depressed frequently note that their thinking is slowed down, that they have trouble concen- trating, and that they are easily distracted. Cathy’s ability to con- centrate was so disturbed that she became unable to work. She had extreme difficulty making even the simplest decisions. After she started staying home, she sat in front of the television set but was un- able to pay attention to the content of even the simplest programs.

Guilt and worthlessness are common preoccupations. De- pressed patients blame themselves for things that have gone wrong, regardless of whether they are in fact responsible. They focus considerable attention on the most negative features of themselves, their environments, and the future—a combination known as the “depressive triad” (Beck, 1967).

Manic episodes are associated with euphoria as well as boundless energy and enthusiasm.

mood disorders and suicide CHAPTER 5 111

manifestation of a mood disorder and other syndromes is referred to as comorbidity, suggesting that the person exhibits symptoms of more than one underlying disorder. The greatest overlap is with anxiety disorders. Among people who meet the diagnostic criteria for major depression at some point during their lives, 60 percent also qualify for a diagnosis of at least one anxiety disorder (Kessler, Merikangas, & Wang, 2007).

Alcoholism and depression are also closely related phenom- ena. Many people who are depressed also drink heavily, and many people who are dependent on alcohol—approximately 40 percent—have experienced major depression at some point during their lives (Swendsen & Merikangas, 2000). The order of onset for the depression and alcoholism varies from one person to the next. Some people become depressed after they develop a drink- ing problem; others begin drinking after being depressed.

Diagnosis Many alternative approaches have been proposed for the diagno- sis of mood disorders over the past 100 years. Two primary issues have been central in debates about these systems. First, should mood disorders be defined in a broad or a narrow fashion? A nar- row approach to the definition of depression would focus on the most severely disturbed people—those whose depressed mood seems to be completely unrelated to any precipitating events, is entirely pervasive, and is completely debilitating. A broader ap- proach to the definition would include milder forms of depres- sion. Some recent critics have argued that the current diagnostic system has expanded the definition of depression to include nor- mal sadness because it does not exclude reactions to a wide array of negative events, such as betrayal by a romantic partner or fail- ing to reach an important life goal (Horwitz & Wakefield, 2007). This issue is, of course, a question about the validity of this di- agnostic category (see Chapter 4). Is depression necessarily “nor- mal” if it follows a stressful event? The resolution of this debate depends on several issues, including the consideration of research evidence (see Thinking Critically About DSM-5).

The second issue regarding the diagnosis of mood disorders concerns heterogeneity. All depressed patients do not have exactly the same set of symptoms, the same pattern of onset, or the same course over time. Some patients have manic episodes, whereas others experience only depression. Some exhibit psychotic symp- toms, such as delusions and hallucinations, in addition to their symptoms of mood disorder; others do not. In some cases, the person’s depression is apparently a reaction to specific life events, whereas in others the mood disorder seems to come out of no- where. Are these qualitatively distinct forms of mood disorder, or are they different expressions of the same underlying problem? Is the distinction among the different types simply one of severity?

The DSM-5 approach to classifying mood disorders recog- nizes two distinct types: depressive disorders and bipolar disor- ders. The manual also lists additional forms of depressive and bipolar disorder under each of those major headings.

Early-morning waking is often associated with particularly severe depression. A less common symptom is for a depressed individual to spend more time sleeping than usual.

In the midst of a manic episode, a person is likely to expe- rience a drastic reduction in the need for sleep. Some patients report that reduced sleep is one of the earliest signs of the onset of an episode. Although depressed patients typically feel exhausted when they cannot sleep, a person in a manic episode will prob- ably be bursting with energy in spite of the lack of rest.

Depressed people frequently experience a change in appetite. Although some patients report that they eat more than usual, most reduce the amount that they eat; some may eat next to nothing. Food just doesn’t taste good any more. Depressed people can also lose a great deal of weight, even without trying to diet.

People who are severely depressed commonly lose their in- terest in various types of activities that are otherwise sources of pleasure and fulfillment. One common example is a loss of sexual desire. Depressed people are less likely to initiate sexual activity, and they are less likely to enjoy sex if their partners can persuade them to participate.

Various ill-defined somatic complaints can also accompany mood disorders. Some patients complain of frequent headaches and muscular aches and pains. These concerns may develop into a preoccupation with bodily functions and fear of disease.

Behavioral Symptoms The symptoms of mood disorders also include changes in the things that people do and the rate at which they do them. The term psychomotor retardation refers to several features of behavior that may accompany the onset of serious depression. The most obvious behavioral symptom of depression is slowed move- ment. Patients may walk and talk as if they are in slow motion. Others become completely immobile and may stop speaking alto- gether. Some depressed patients pause for very extended periods, perhaps several minutes, before answering a question.

In marked contrast to periods when they are depressed, manic patients are typically gregarious and energetic. Debbie’s behavior provided many examples, even after her admission to the psychiatric hospital. Her flirtatious and provocative behavior on the ward was clearly inappropriate. She found it impossible to sit still for more than a moment or two. Virtually everything was interesting to her, and she was easily distracted, flitting from one idea or project to the next. Like other manic patients, Debbie was full of plans that were pursued in a rather indiscriminate fashion. Excessive pursuit of life goals is frequently associated with the on- set of manic episodes.

Other Problems Commonly Associated with Depression Many people with mood disorders suffer from some clinical problems that are not typically considered symptoms of depres- sion. Within the field of psychopathology, the simultaneous

112 CHAPTER 5 mood disorders and suicide

absence of any history of manic episodes. DSM5: Criteria for Major Depressive Episode lists the DSM-5 criteria for major depressive epi- sode. Although some people experience a single, isolated episode of major depression followed by complete recovery, most cases of depression follow an intermittent course with repeated episodes.

Persistent depressive disorder (dysthymia) differs from major depression in terms of both severity and duration. Persis- tent depressive disorder represents a chronic mild depressive con- dition that has been present for many years. In order to fulfill

DEPrESSivE DiSOrDErS Depressive disorders include three main types among adults: major depressive disorder, persistent depressive disorder (also known as dysthymia), and premenstrual dysphoric disorder. A fourth type of depressive disorder, known as disruptive mood dysregulation disorder, was added with the publication of DSM-5. It is intended to describe children with chronic, severe irritability (see Chapter 16).

In order to meet the criteria for major depressive disorder, a person must experience at least one major depressive episode in the

Thinking CriTiCally about DSM-5

Depression or Grief Following a Major Loss?

Depression often begins after a person goes through a neg-ative life event. These experiences can take many forms, such as breaking up with a romantic partner, loss of a job, or onset of a life-threatening illness. In DSM-IV, the diagnostic criteria for an episode of major depression provided an exception for one specific type of event. People who had recently experi- enced the death of a close relative or friend could not qualify for a diagnosis of depression until two months after the loss. This “bereavement exclusion” was eliminated for DSM-5, and the change ignited a firestorm of controversy.

Critics of the change argue that it will turn normal grief into a form of illness, expanding even farther the boundaries of mental disor- ders (Frances, 2013; Wakefield, 2011). People who are grieving the loss of a loved one may indeed show symptoms of depression, and their sadness can become intense. Many experience sleep prob- lems, loss of interest in other activities, and trouble concentrating. These symptoms are usually transient, and most people who are recovering from the loss of a loved one do not think of themselves as having a mental disorder. Of course, some people do develop a full-blown episode of depression following a loss, and treatment becomes an important option for them. The bereavement exclu- sion was developed in order to distinguish between these cases and those for whom symptoms are only temporary. Its purpose was to minimize the number of “false positives,” that is, normally grieving people who would have been assigned a diagnosis of depression if not for the bereavement exclusion.

What’s wrong with waiting two months to assign a diagnosis of depression? At a practical level, it could delay access to much- needed treatment. At a more conceptual level, the bereave- ment exclusion is arbitrary and illogical. All kinds of stressful and traumatic events can lead to the onset of major depression. Divorce, sudden financial hardships, and the need to assume un- expected family responsibilities (e.g., caring for a family member who suddenly becomes ill) are obvious example of events that can be devastating. Why aren’t people who experience those events also excluded from a diagnosis of depression until two months after the event? In order to be consistent, the diagnostic manual would either need to expand the exclusion to cover all stressful life events or eliminate the bereavement exclusion. The

workgroup for mood disorders chose the latter option. That was one reason for the change in DSM-5.

The decision also hinged on research evidence regarding de- pression following loss of a partner or other close relative. Is their depression somehow different from other forms of de- pression? Several research studies have addressed this issue, comparing two groups of people: (1) those who meet criteria for major depression and are not bereaved and (2) those who meet criteria for major depression and are bereaved (and who would otherwise be excluded from the diagnosis using the grief rule-out). Arguments in favor of the exclusion depend on finding that the two groups are different in important ways. For example, it might be expected that the grieving people would have a later age of onset, fewer previous episodes, a shorter duration of episodes, or fewer recurrent episodes in the future. None of those differences have been found (Kendler, Myers, & Zisook, 2008). In other words, depression following loss of a loved one is not different from other forms of depression. Therefore, it seems illogical to subdivide cases on this basis.

Public outcry about elimination of the grief exclusion has made some exaggerated claims, such as the notion that people who are grieving will now be exposed to unnecessary treatments, in- cluding antidepressant medication. Some fear that bereavement will be stigmatized. In fact, most grieving people do not meet diagnostic criteria for major depression. That is not to say that they do not experience sadness or loneliness that is extremely difficult to endure. But there are several important features of major depression that make it distinct from these other forms of emotional distress (see Table 5.2).

Finally, it is clearly left to the discretion of mental health profes- sionals to decide, on the basis of their own judgment and clinical experience, whether to initiate some form of treatment for a person who qualifies for the diagnosis of major depression. Rec- ognizing that a patient is grieving might lead the clinician to wait and see how things progress. But in the face of, for example, serious suicidal thoughts, a more active intervention might be pursued. Treatment remains an option that should be pursued by joint agreement of the therapist and the patient.

mood disorders and suicide CHAPTER 5 113

DSM-5 criteria for this disorder, the person must, over a period of at least two years, exhibit a depressed mood for most of the day on more days than not. Two or more of the following symptoms must also be present:

1. Poor appetite or overeating

2. Insomnia or hypersomnia

3. Low energy or fatigue

4. Low self-esteem

5. Poor concentration or difficulty making decisions

6. Feelings of hopelessness

These symptoms must not be absent for more than two months at a time during the two-year period. If, at any time during the initial two years, the person met criteria for a ma- jor depressive episode, the diagnosis would be major depression rather than persistent depressive disorder. As in the case of major

Most people who are grieving the loss of a loved one do not become clinically depressed, but some do. The “bereavement exclusion” was dropped from DSM-5, in part, because this is only one of many types of stressful life events can lead to the onset of an episode of depression.

criteria for Major Depressive Episode DSM-5

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

A. Five (or more) of the following symptoms have been pres- ent during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly attribut- able to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicat- ed by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either sub jective account or observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)

4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day

(observable by others; not merely subjective feelings of restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate

guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as ob- served by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impair- ment in social, occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or another medical condition.

Note: Criteria A–C represent a major depressive episode.

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a sig- nificant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expres- sion of distress in the context of loss.1

D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanic episode.

Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.

114 CHAPTER 5 mood disorders and suicide

cycle and are then diminished at the onset or shortly after men- ses. Symptoms include mood lability, irritability, dysphoria, and anxiety as well as cognitive (difficulty concentrating, feeling of being overwhelmed or out of control), and somatic symptoms (e.g., lethargy, changes in appetite, sleep problems, joint or mus- cle pain, a sensation of bloating, etc.). In order to meet the di- agnostic criteria for this disorder, a woman must exhibit at least five of these symptoms, and at least one of those symptoms must involve a disturbance in mood (e.g., mood swings or marked irritability). The symptoms must have been present for most of the woman’s menstrual cycles in the past year, and they must be associated with clinically significant distress or interference with social or occupational functioning (Hartlage et al., 2012).

BiPOLAr DiSOrDErS All three types of bipolar disorders involve manic or hypomanic episodes. DSM5: Criteria for Diagnosis of Manic Episode lists the DSM-5 criteria for a manic episode. The mood disturbance must be severe enough to interfere with occupational or social functioning. A person who has experienced at least one manic episode would be assigned a diagnosis of bipolar I disorder. The vast majority of patients with this disorder have episodes of major depression in addition to manic episodes.

Some patients experience episodes of increased energy that are not sufficiently severe to qualify as full-blown mania. These episodes are called hypomania. A person who has experienced at least one major depressive episode, at least one hypomanic episode, and no full-blown manic episodes would be assigned a

depressive disorder, the presence of a manic episode would rule out a diagnosis of persistent depressive disorder.

The distinction between major depressive disorder and per- sistent depressive disorder is somewhat artificial because both sets of symptoms are frequently seen in the same person. In such cases, rather than thinking of them as separate disorders, it is more appropriate to consider them as two aspects of the same disorder, which waxes and wanes over time. Some experts have argued that chronic depression is a single, broadly conceived dis- order that can be expressed in many different combinations of symptoms over time (McCullough et al., 2003).

Premenstrual dysphoric disorder (PMDD) was added as a new diagnostic category in DSM-5. Previous versions of the diagnostic manual had listed this category in the appendix, under “disorders provided for further study.” Members of the DSM-5 workgroup for mood disorders decided that sufficient evidence had been ac- cumulated to justify its inclusion as a formal diagnostic  category ( Epperson et al., 2012). Women commonly experience premenstrual symptoms that center around emotional and physical complaints, but they are typically mild. A few experience these symptoms in greater numbers and with increased severity, to the extent that they are associated with obvious social and occupational impairment. These are the people for whom PMDD may be an appropriate di- agnosis (Cunningham et al., 2009). It should be noted, however, that this category remains controversial, with questions being raised about the validity of its diagnostic criteria (Callaghan et al., 2009).

PMDD is defined in terms of various mood-related symp- toms that occur repeatedly during the premenstrual phase of the

criteria for Diagnosis of Manic Episode DSM-5

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and per- sistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symp- toms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only

3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are

racing. 5. Distractibility (i.e., attention too easily drawn to

unimportant or irrelevant external stimuli), as reported or observed.

6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non goal-directed activity).

7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.

Note: A full manic episode that emerges during antide- pressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.

mood disorders and suicide CHAPTER 5 115

a term that is used to describe a particularly severe type of depres- sion. Some experts believe that melancholia represents a subtype of depression that is caused by different factors than those that are responsible for other forms of depression (Parker et al., 2010). The presence of melancholic features may also indicate that the person is likely to have a good response to biological forms of treatment, such as antidepressant medication and electroconvul- sive therapy (Taylor & Fink, 2008).

In order to meet the DSM-5 criteria for melancholic features, a depressed patient must either (1) lose the feeling of pleasure associated with all, or almost all, activities or (2) lose the capac- ity to feel better—even temporarily—when something good hap- pens. The person must also exhibit at least three of the following: (1) The depressed mood feels distinctly different from the depres- sion a person would feel after the death of a loved one; (2) the depression is most often worst in the morning; (3) the person awakens early, at least two hours before usual; (4) marked psycho- motor retardation or agitation; (5) significant loss of appetite or weight loss; and (6) excessive or inappropriate guilt.

Another episode specifier allows the clinician to indicate the presence of psychotic features—hallucinations or delusions— during the most recent episode of depression or mania. The psy- chotic features can be either consistent or inconsistent with the patient’s mood. For example, if a depressed man reports hearing voices that tell him he is a worthless human being who deserves to suffer for his sins, the hallucinations would be considered “mood congruent psychotic features.” Depressed patients who ex- hibit psychotic features are more likely to require hospitalization and treatment with a combination of antidepressant and antipsy- chotic medication (Parker et al., 1997).

Another episode specifier applies to women who become depressed or manic following pregnancy. A major depressive or manic episode can be specified as having a postpartum onset if it begins within four weeks after childbirth. Because the woman must meet the full criteria for an episode of major depression or ma- nia, this category does not include minor periods of postpartum “blues,” which are relatively common (Seyfried & Marcus, 2003).

The DSM-5 course specifiers for mood disorders allow clinicians to describe further the pattern and sequence of epi- sodes, as well as the person’s adjustment between episodes. For example, the course of a bipolar disorder can be specified as rapid cycling if the person experiences at least four episodes of major depression, mania, or hypomania within a 12-month pe- riod. Patients whose disorder follows this problematic course are likely to show a poor response to treatment and are at greater risk than other types of bipolar patients to attempt suicide ( Coryell et al., 2003).

A mood disorder (either depressive or bipolar) is described as following a seasonal pattern if, over a period of time, there is a regular relationship between the onset of a person’s episodes and particular times of the year. The most typical seasonal pattern is one in which the person becomes depressed in the fall or winter, followed by a full recovery in the following spring or summer.

diagnosis of bipolar II disorder. The symptoms used in DSM-5 to identify a hypomanic episode are the same as those used for manic episode (at least three of the seven symptoms listed in DSM5: Criteria for Diagnosis of Manic Episode). The differences between manic and hypomanic episodes involve duration and se- verity. The symptoms need to be present for a minimum of only four days to meet the threshold for a hypomanic episode (as op- posed to one week for a manic episode). The mood change in a hypomanic episode must be noticeable to others, but the distur- bance must not be severe enough to impair social or occupational functioning or to require hospitalization.

Cyclothymia is considered by DSM-5 to be a chronic but less severe form of bipolar disorder. It is, therefore, the bipolar equivalent of persistent depressive disorder. In order to meet cri- teria for cyclothymia, the person must experience several periods of time with hypomanic symptoms and frequent periods of de- pression (or loss of interest or pleasure) during a period of two years. There must be no history of major depressive episodes and no clear evidence of a manic episode during the first two years of the disturbance.

FurThEr DESCriPTiONS AND SuBTYPE DSM-5 includes several additional ways of describing subtypes of the mood disor- ders. These are based on two considerations: (1) more specific de- scriptions of symptoms that were present during the most recent episode of depression (known as episode specifiers) and (2) more extensive descriptions of the pattern that the disorder follows over time (known as course specifiers). These distinctions may provide a useful way to subdivide depressed patients, who certainly present a heterogeneous set of problems. On the other hand, the validity of these subtypes is open to question, especially those based on episode specifiers. Long-term follow-up studies suggest that a pa- tient’s subtype diagnosis is likely to change over repeated episodes (Angst, Sellaro, & Merikangas, 2000).

One episode specifier allows the clinician to describe a major depressive episode as having melancholic features. Melancholia is

MyPsychlab ViDEO CaSE

Bipolar Disorder with Psychotic Features

ANN

“I felt very tense, like my mind was rac- ing; that I was making unusual connec- tions; that I couldn’t sleep at night.”

Watch the Video Ann: Bipolar Disorder on MyPsychLab

Although Ann’s manic episodes were associated with increased productivity, they also led to serious occupational and social problems.

116 CHAPTER 5 mood disorders and suicide

Depressive Disorders People with depressive mood disorders typically have their first episode in their early thirties; the average age of onset is 32 (Kessler et al., 2007). The length of episodes varies widely. DSM-5 sets the minimum duration at two weeks, but they can last much longer. Most depressive patients will have at least two depressive episodes. The mean number of lifetime episodes is five or six.

The results of long-term follow-up studies of treated patients indicate that major depressive disorder is frequently a chronic and recurrent condition in which episodes of severe symptoms may alternate with periods of full or partial recovery (Thase, 2003). When a person’s symptoms are diminished or improved, the dis- order is considered to be in remission, or a period of recovery. Relapse is a return of active symptoms in a person who has re- covered from a previous episode. These phases of the disorder are represented schematically in Figure 5.1.

Approximately half of all depressive patients recover within six months of the beginning of an episode. After recovery from an episode of major depression, the risk of relapse goes down as the period of remission increases. In other words, the longer the person remains free of depression, the better his or her chance of avoiding relapse (Hart, Craighead, & Craighead, 2001).

Bipolar Disorders Onset of bipolar disorders usually occurs between the ages of 18 and 22 years, which is younger than the average age of onset for depressive disorders. The first episode is just as likely to be manic as depressive. The average duration of a manic episode runs be- tween two and three months. The onset of a manic episode is not always sudden. Jamison noted, for example:

I did not wake up one day to find myself mad. Life should be so simple. Rather, I gradually became aware that my life and mind were going at an ever faster and faster clip until finally, over the course of my first summer on the faculty, they both had spun wildly and absolutely out of control. But the acceleration from quick thought to chaos was a slow and beautifully seductive one. (1995, p. 68)

Researchers refer to a mood disorder in which the onset of episodes is regularly associated with changes in seasons as seasonal affective disorder.1 The episodes most commonly occur in win- ter, presumably in response to fewer hours of sunlight. Seasonal depression is usually characterized by somatic symptoms, such as overeating, carbohydrate craving, weight gain, fatigue, and sleeping more than usual. Among outpatients who have a history of at least three major depressive episodes, approximately one out of six will meet criteria for the seasonal pattern (Westrin & Lam, 2007). Most patients with seasonal affective disorder have a depressive disorder.

Course and Outcome To describe the typical sequence over time and outcome of mood disorders, it is useful to consider depressive and bipolar disorders separately. Most studies point to clear-cut differences between these two conditions in terms of age of onset and prognosis.

Many new mothers experience transient symptoms of the “baby blues” (e.g., trouble sleeping, tearfulness, feeling overwhelmed), but postpar- tum depression is more than that. The person meets full diagnostic criteria for depression.

figure 5.1 The Course of an Episode of Major Depression The phases leading into (and out of) an episode of depression. Source: Frank E, Swartz HA, Kupfer DJ. Interpersonal and social rhythm therapy: managing the chaos of bipolar disorder. Biological Psychiatry. 2000 Sep 15;48(6):593–604.

Normal Mood

Low or Depressed Mood

Remission

Progression to Disorder

Relapse

Full Syndrome of Depression

1“Affect” and “mood” are sometimes used interchangeably in psychiatric terminology. Depression and mania were called “affective disorders” in DSM-III.

mood disorders and suicide CHAPTER 5 117

for bipolar I and II disorders combined was close to 4 percent. Taken together, depressive disorders are much more common than bipolar disorders. The ratio of depressive to bipolar disorders is at least 5:1 (Kessler & Wang, 2008).

Evidence regarding the prevalence of premenstrual dysphoric disorder is, of course, preliminary because it has been added re- cently to the diagnostic manual. It has not been included as a category in any of the large-scale epidemiological studies in the United States. As many as 8 percent of women experience moder- ate to severe symptoms of premenstrual dysphoric disorder, and one study reported that 3 percent meet the diagnostic criteria for this disorder (Cunningham et al., 2009; Tschudin et al. 2010).

Because the NCS-R study identified a representative sample of community residents rather than patients already in treatment, it provides some insight regarding the proportion of depressed people who seek professional help for their problems. Slightly more than 20 percent of those people who met diagnostic criteria for a mood disorder in the past 12 months had received adequate treatment during that same time period. These data indicate that a substantial proportion of people who are clinically depressed do not receive professional treatment for their disorders. Finding ways to help these people represents an important challenge for psychologists and psychiatrists who treat mood disorders.

risk for Mood Disorders Across the Life Span Age is an important consideration in the epidemiology of mood disorders. Some readers might expect that the prevalence of depression would be higher among older people than among younger people. This was, in fact, what many clinicians expected prior to large-scale epidemiological investigations, such as the NCS-R. This belief may stem from the casual observation that many older people experience brief episodic states of acute un- happiness, often precipitated by changes in status (e.g., retire- ment, relocation) and loss of significant others (e.g., children

The long-term course of bipolar disorders is most often inter- mittent (Cuellar, Johnson, & Winters, 2005). Most patients have more than one episode, and bipolar patients tend to have more episodes than depressive patients. The length of intervals between episodes is difficult to predict. The long-term prognosis is mixed for patients with bipolar disorder. Although some patients recover and function very well, others experience continued impairment. Several studies that have followed bipolar patients over periods of up to 10 years have found that approximately half of the people are able to achieve a sustained recovery from the disorder. On the other hand, many patients remain chronically disabled. Watch the Video Feliziano: Living with Bipolar Disorder on MyPsychLab

Frequency Several studies provide detailed information regarding the frequency of mood disorders in various countries around the world (Kessler, Merikangas, & Wang, 2007). Some are based on information col- lected from nonclinical samples of men and women by investigators using structured diagnostic interviews. In other words, the people who participated in these studies did not have to be in treatment at a hospital or clinic in order to be identified as being depressed. These studies are particularly important because large numbers of people experience serious depression without wanting or being able to seek professional help. Data based exclusively on treatment records would underestimate the magnitude of the problem.

incidence and Prevalence Depression is one of the most common forms of psychopathology. In a representative sample of more than 9,000 people who were inter- viewed for the National Comorbidity Survey Replication (NCS-R), approximately 16 percent suffered from major depressive disorder at some point during their lives. Lifetime risk for persistent depressive disorder (dysthymia) was approximately 3 percent. The lifetime risk

Contrary to popular views, older people are actually less likely to be depressed than are younger people. Some subgroups of elderly people, however, are at high risk for depression.

118 CHAPTER 5 mood disorders and suicide

years? The answer is apparently yes. People born after World War II seem to be more likely to develop mood disorders than were people from previous generations. In fact, several studies have re- ported a consistent trend toward higher lifetime rates of depres- sion in successively younger generations. The average age of onset for clinical depression also seems to be lower in people who were born more recently (Kessler et al., 2005).

Gender Differences Women are two or three times more vulnerable to depression than men are (Kessler, 2006; Van de Velde et al., 2010). This pattern has been reported in study after study, using samples of treated patients as well as community surveys, and regardless of the assess- ment procedures employed. The increased prevalence of depres- sion among women is apparently limited to depressive disorders. Gender differences are not typically observed for bipolar disorders.

Some observers have suggested that the high rates for depres- sion in women reflect shortcomings in the data collection process. Women simply might be more likely than men to seek treatment or to be labeled as being depressed. Another argument holds that culturally determined sanctions make it more difficult for men to admit to subjective feelings of distress, such as hopelessness and despair. None of these alternatives has been substantiated by em- pirical evidence. Research studies clearly indicate that the higher prevalence of depression among women is genuine. Possible ex- planations for this gender difference have focused on a variety of factors, including sex hormones, stressful life events, and child- hood adversity as well as response styles that are associated with gender roles (Hankin & Abramson, 2001; Kuehner, 2003). These issues are discussed later in this chapter.

Cross-Cultural Differences Comparisons of emotional expression and emotional disorder across cultural boundaries encounter a number of methodologi- cal problems (see Research Methods in Chapter 9). One problem involves vocabulary. Each culture has its own ways of interpreting reality, including different styles of expressing or communicating symptoms of physical and emotional disorder. Words and concepts that are used to describe illness behaviors in one culture might not exist in other cultures. For example, some African cultures have

moving away, deaths of friends and relatives). But brief episodes of sadness and grief are not the same thing as clinical depression.

Although many people mistakenly identify depression with the elderly, data from the NCS-R project suggest that mood disorders are most frequent among young and middle-aged adults. These data are illustrated in Figure 5.2. Prevalence rates for major depressive disorder, persistent depressive disorder, and bipolar disorder were all significantly lower for people over the age of 60.

Several explanations have been offered for this pattern. One interpretation is based on the fact that elderly people are more likely to experience memory impairments (see Chapter 14). Peo- ple who are in their sixties and seventies may have more trouble remembering, and therefore may fail to report, episodes of de- pression that occurred several months or years before the research interview is conducted. Also, because mood disorders are asso- ciated with increased mortality (e.g., suicide), many severely de- pressed people might not have survived into old age. These are plausible hypotheses that may have influenced the results of the NCS-R study. Nevertheless, the same pattern has been observed in several studies, and most investigators now believe that the ef- fect is genuine: Clinical depression is less common among elderly people than it is among younger adults (Blazer, 2004).

The findings on age and depression also raise another impor- tant question: Has the frequency of depression increased in recent

figure 5.2 Lifetime Prevalence of Mood Disorders by Age (NCS-r data) Lifetime prevalence of major depression, persistent depressive disorder (dysthymia), and bipolar disorder in a representative community sample. Source: Based on Kessler et al. Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry. 2005; 62.

5

10

15

20

60 and older18–29 30–44 45–59 0

Age Groups

Pr ev

al en

ce (p

er ce

nt ) Major

Depressive Disorder

Dysthymia

Bipolar Disorders

MyPsychlab ViDEO CaSE

Major Depression

EVERETT

“You feel absolute worthlessness. You feel there is no hope for the future.”

Watch the Video Everett: Major Depression on MyPsychLab

Watch the video “Major Depression: Everett” on MyPsychLab. Notice the importance and

persistence of the negative way in which he views himself and his abilities.

mood disorders and suicide CHAPTER 5 119

other people—may represent a response system that helps the person disengage from a situation that is not going well (Nesse, 1999; Taylor et al., 2011). For example, someone who is involved in an unsuccessful marriage may eventually become depressed, withdrawn, and reconsider the long-term benefits of investing further time and resources in a relationship that is likely to re- main unrewarding. At low levels and over brief periods of time, depressed mood may help us refocus our motivations, and it may help us to conserve and redirect our energy in response to experi- ences of loss and defeat.

Psychological explanations for mood disorders focus on in- dividual differences, and they are primarily concerned with the most severe and disabling forms of depression. Following difficult and challenging experiences, why do some people develop major depression and others do not? What factors are responsible for a relatively drastic failure of the psychological and biological sys- tems that regulate mood? A disorder that is as common as depres- sion must have many causes rather than one.

Our consideration of cause is organized around different lev- els of analysis. We will consider social, psychological, and biological mechanisms that are involved in the onset and maintenance of mood disorders. This organization should help you appreciate the comple- mentary nature of these analyses. After we have considered the im- pact of stressful life events on mood, we will discuss psychological factors, such as cognitive biases, that shape a person’s response to stress. Then we will review what is known about hormones and brain activities that coordinate our responses to environmental stressors.

Social Factors It should not be surprising that much of the literature on mood disorders is focused on interpersonal loss and separation. From birth to death, our lives are intertwined with those of other peo- ple. We are fundamentally social organisms, and we feel sad when someone close to us dies or a relationship ends. Similar feelings occasionally follow major disappointments, such as failure to win acceptance to the school of our choice or being fired from a job. In these cases, rather than losing other people, some clinicians have suggested that we may be losing “social roles” or ways in which we think about ourselves. Clues to the causes of depression may be found in studying these experiences of normal sadness. The onset and maintenance of clinical depression clearly involve a disruption or failure of the normal mechanisms that regulate the negative emotions following major losses.

STrESSFuL LiFE EvENTS AND DEPrESSivE DiSOrDErS Several investigations have explored the relationships between stressful life events and the development of depressive disorders. Do people who become clinically depressed actually experience an increased number of stressful life events? The answer is yes. The experience of stressful life events is associated with an in- creased probability that a person will become depressed. This correlation has been demonstrated many times (Hammen, 2005; Monroe & Reid, 2009).

only one word for both anger and sadness. Interesting adaptations are, therefore, required to translate questions that are supposed to tap experiences, such as anxiety and depression. One investiga- tion, which employed a British interview schedule that had been translated into Yoruba—a language spoken in Nigeria—used the phrase “the heart goes weak” to represent depression (Leff, 1988). Our own diagnostic categories have been developed within a spe- cific cultural setting; they are not culture-free and are not neces- sarily any more reasonable than the ways in which other cultures describe and categorize their own behavioral and emotional disor- ders (Lavender, Khodoker, & Jones, 2006).

Cross-cultural differences have been confirmed by a num- ber of research projects that have examined cultural variations in symptoms among depressed patients in different countries. These studies report comparable overall frequencies of mood disorders in various parts of the world, but the specific type of symptom expressed by the patients varies from one culture to the next. In Chinese patients, depression is more likely to be described in terms of somatic symptoms, such as sleeping problems, head- aches, and loss of energy (Kleinman, 2004). Depressed patients in Europe and North America are more likely to express feelings of guilt and suicidal ideas (Kirmayer, 2001).

These cross-cultural comparisons suggest that, at its most ba- sic level, clinical depression is a universal phenomenon that is not limited to Western or urban societies. They also indicate that a person’s cultural experiences, including linguistic, educational, and social factors, may play an important role in shaping the manner in which he or she expresses and copes with the anguish of depression. Cross-cultural variations should also be kept in mind when clini- cians attempt to identify central or defining features of depression. We will return to this point later in the chapter when we discuss the rationale behind studies that rely on animal models of depression.

Causes In the next few pages we turn our attention to current specula- tion and knowledge about causes of mood disorders. Discussions of this topic must keep in mind the relatively high prevalence of these problems. Major depression is a severely disabling condi- tion that affects at least 16 percent of the population, usually appearing during young adulthood when the person would be expected to be most active and productive. Why hasn’t this prob- lem been eliminated through the process of natural selection? Evolutionary theorists suggest that it is because, in addition to being painful and disruptive to a person’s life, mild to moder- ate symptoms of depression may serve a useful purpose ( Gilbert, 2006; Price, Gardner, & Erickson, 2004). This argument is focused on those situations in which depression represents a temporary response to circumstances in the person’s environ- ment. As we will see, many episodes of depression do seem to be triggered by stressful life events and harsh social circumstances. An evolutionary perspective would hold that the symptoms of depression—slowing down, loss of motivation, withdrawal from

120 CHAPTER 5 mood disorders and suicide

Severe events increase the probability of depression, but most women who experience a severe event do not become depressed. What is the difference between the circumstances of women who become depressed after a severe event and those who do not? Some evidence suggests that depression is more likely to occur when severe life events are associated with feelings of humiliation, entrapment, and defeat (Brown, 2002; Nanni et al., 2012). An example of a humiliating event would be a woman learning un- expectedly of her husband’s long-standing infidelity. An example of an event fitting the entrapment theme would be a woman re- ceiving official notification that her application to move out of appalling housing conditions had been denied. These data point to a particularly powerful relationship between the onset of de- pression and certain kinds of stressful life events. The likelihood that a woman will become depressed is especially high if she ex- periences a severe event that would be expected to lead to a sense of being devalued as a person or trapped with no way toward a brighter future (Kendler et al., 2003).

In fact, the relationship between stressful life events and de- pression actually runs in both directions. Some depressed people create difficult circumstances that increase the level of stress in their lives. Examples include breaking up with a romantic partner or being fired from a job. This phenomenon is known as stress generation. In comparison to people who are not depressed, de- pressed people generate higher levels of stress, especially in the context of interpersonal relationships (Hammen, 2005; Harkness & Stewart, 2009). Maladaptive tactics for coping with marital distress are important factors in this process. For example, when involved in a serious disagreement with a spouse, a depressed per- son might express escalating complaints and hostile, provocative comments rather than trying to work toward a solution to the conflict. This dynamic process leads to an escalation of stress.

Gender differences in the frequency and nature of stressful life events may help to explain gender differences in the prevalence of major depression. Some research evidence indicates that women who are depressed are more likely than men to report that they experienced a severe life event in the months prior to the onset of their mood disorder (Harkness et al., 2010). Furthermore, it is spe- cifically negative interpersonal stress that seems to have a particu- larly detrimental impact in the lives of young women (Cyranowski & Frank, 2006; Shih & Eberhart, 2010). Women may be more likely to generate interpersonal stress and to suffer from its con- sequences because they are more likely than men to invest in, and base their evaluations of themselves upon, the importance of re- lationships with other people. Men, on the other hand, are more likely to focus on the importance of individual accomplishments related to school, work, and sports (Crick & Zahn-Waxler, 2003).

SOCiAL FACTOrS AND BiPOLAr DiSOrDErS Most investiga- tions of stressful life events have been concerned with depressive disorders. Less attention has been paid to bipolar disorders, but some have found that the weeks preceding the onset of a manic episode are marked by an increased frequency of stressful life

Investigators have faced difficult methodological issues in order to interpret the strong relationship between stressful life events and the onset of depression. One particularly troublesome problem involves the direction of the relationship between life events and mood disorders. For example, being fired from a job might lead a person to become depressed. On the other hand, the onset of a depressive episode, with its associated difficulties in energy and concentration, could easily affect the person’s job per- formance and lead to being fired. Therefore, if depressed people experience more stressful events, what is the direction of effect? Does failure lead to depression, or does depression lead to failure?

By using prospective research designs, in which subjects are followed over time, investigators have been able to ad- dress the question of cause and effect (see Research Methods in Chapter 8). Prospective studies have found that stressful life events are useful in predicting the subsequent onset of depres- sion (Brown, 2002; Monroe & Harkness, 2005). This evidence supports the argument that, in many cases, stressful life events contribute to (and are not merely consequences of ) the onset of mood disorders.

Although many kinds of negative events are associated with depression, a special class of circumstances—those involving ma- jor losses of important people or roles—seems to play a crucial role in precipitating major depression, especially a person’s first lifetime episode. This conclusion is based, in large part, on a se- ries of studies that have compared the living circumstances and life experiences of depressed and nondepressed women (Brown & Harris, 1978). Severe events—those that are particularly threat- ening and have long-term consequences for the woman’s ad- justment—increase the probability that a woman will become depressed. On the other hand, the ordinary hassles and difficul- ties of everyday living (events that are not severe) do not seem to lead to the onset of depression (Stroud et al., 2010).

A series of studies comparing the life experiences of women in six communities—including Harare, Zimbabwe—found that the greater the frequency of severe events, the higher the prevalence of depression.

mood disorders and suicide CHAPTER 5 121

stressful life events. In the following pages, we will consider two principal areas that have received attention in the research litera- ture: cognitive factors and social skills.

COGNiTivE vuLNErABiLiTY Cognitive theories concerning the origins of depression are based on the recognition that humans are not only social organisms, they are also thinking organisms, and the ways in which people perceive, think about, and remem- ber events in their world can have an important influence on the way that they feel. Two people may react very differently to the same event, in large part because they may interpret the event dif- ferently. Cognitive theories about vulnerability to depression have focused on the ways in which people attend to, think about, and recall information from their environment. Most often, this in- volves cognitive activity related to experiences involving loss, fail- ure, and disappointment. According to the cognitive perspective, pervasive and persistent negative thoughts about the self and pes- simistic views of the environment play a central role in the onset and subsequent maintenance of depression after these thoughts are activated by the experience of a negative life event (Gotlib & Joormann, 2010; Mathews & MacLeod, 2005).

Various types of distortions, errors, and biases are charac- teristic of the thinking of depressed people. One is the tendency to assign global, personal meaning to experiences of failure. An example might be a person who has been turned down after he tried out for a competitive sports team and says to himself, “This proves that I am a failure” rather than acknowledging that many talented people were being considered, that only a few people could be retained, and difficult decisions had to be made by the coach. Another cognitive distortion associ- ated with depression is the tendency to overgeneralize conclu- sions about the self based on negative experiences. Following the example raised earlier, the person might also say to himself, “The fact that I was cut from the team shows that I am also going to fail at everything else.” A third type of cognitive er- ror involves drawing arbitrary inferences about the self in the absence of supporting evidence (often in spite of contradictory evidence). In this regard, consider a player who is a member of an athletic team. If the team loses a game and the coach is up- set, the player might arbitrarily decide that the loss was his fault and the coach doesn’t like him, even though nothing about his performance was particularly instrumental with regard to the team’s performance in the game. The final type of cognitive bias related to depression is the tendency to recall selectively events with negative consequences and to exaggerate the importance of negative events while simultaneously discounting the signifi- cance of positive events. For example, suppose that an athlete is looking back over her experiences during the course of an entire season. She would be more likely to feel depressed about her performance if she tends to dwell on the mistakes that she made and the games that the team lost rather than emphasizing the positive contributions that she made and the successes that she shared with her teammates.

events (Bender & Alloy, 2011; Miklowitz & Johnson, 2009). The kinds of events that precede the onset of mania tend to be differ- ent from those that lead to depression. While the latter include primarily negative experiences involving loss and low self-esteem, the former include schedule-disrupting events (such as loss of sleep) as well as goal attainment events. Some patients experience an increase in manic symptoms after they have achieved a sig- nificant goal toward which they had been working ( Johnson et al., 2009). Examples of this kind of goal attainment event would be a major job promotion, being accepted to a competitive pro- fessional school program, or the blossoming of a new romantic relationship. These exhilarating experiences, coupled with the person’s ongoing problems with emotion regulation, may con- tribute to a spiral of positive emotion and excess activity that cul- minates in a full-blown manic episode.

Aversive patterns of emotional expression and communica- tion within the family can also have a negative impact on the adjustment of people with bipolar disorders. Longitudinal stud- ies of bipolar patients have focused on the relation between fre- quency of relapse and the emotional climate within their families. Patients living with family members who are hostile toward or critical of the patient are more likely to relapse shortly after being discharged from the hospital (Miklowitz, 2007). Furthermore, bipolar patients who have less social support are more likely to relapse and recover more slowly than patients with higher levels of social support (Cohen et al., 2004). This evidence indicates that the course of bipolar disorder can be influenced by the social environment in which the person is living.

Psychological Factors Severe events are clearly related to the onset of depression, but they do not provide a complete account of who will become de- pressed. Many people who do not become depressed also expe- rience severe events. Presumably, those who become depressed are somehow more vulnerable to the effects of stress. Several psy- chological factors may contribute to a person’s vulnerability to

MyPsychlab ViDEO CaSE

Major Depression and Stressful Life Events

MARTHA

“I felt like I was out of my mind. Every- thing was black. I did not eat. I did not sleep. I can’t taste food. I was very weak.”

Watch the Video Martha: Major Depressive

Disorder on MyPsychLab

What impact did cultural and social factors seem to play in the development and expression of Martha’s depression?

122 CHAPTER 5 mood disorders and suicide

a depressed mood can influence the duration and severity of the mood (Nolen-Hoeksema, 1994, 2000). Two different response styles have been emphasized in this work. Some people respond to feelings of depression by turning their attention inward, con- templating the causes and implications of their sadness. This is called a ruminative style. Writing in a diary or talking extensively with a friend about how one feels is an indication of a ruminative style. Other people employ a distracting style to divert themselves from their unpleasant mood. They work on hobbies, play sports, or otherwise become involved in activities that draw their atten- tion away from symptoms of depression.

The first hypothesis of this model is that people who engage in ruminative responses have longer and more severe episodes of depression than do people who engage in distracting responses. The second hypothesis is that women are more likely to employ a ruminative style in response to depression, whereas men are more likely to employ a distracting style. Because the ruminative style leads to episodes of greater duration and intensity, women are more susceptible to depression than are men.

iNTEGrATiON OF COGNiTivE AND SOCiAL FACTOrS The fac- tors that we have considered in the preceding pages almost certainly work in combination rather than individually. We do not need to decide whether cognitive vulnerabilities are somehow more or less important than stressful life events because they undoubtedly work in combination. The development of depression must be un- derstood in terms of several stages: vulnerability, onset, and main- tenance. Life events and cognitive factors play an important role within each stage (Alloy et al., 2006; Gotlib & Hammen, 1992).

Vulnerability to depression is influenced by experiences during childhood, including events such as being repeatedly neglected or harshly criticized by parents. Negative ways of thinking about the world and dysfunctional interpersonal skills are presumably learned early in life (Ingram & Ritter, 2000). As the child grows up, the combination of biased cognitive schemas and deficits in interper- sonal skills then affects his or her social environment in several ways: It increases the likelihood that the person will enter problematic re- lationships; it diminishes the person’s ability to resolve conflict after it occurs; and it minimizes the person’s ability to solicit support and assistance from other people (Hammen & Garber, 2001).

The onset of depression is most often triggered by life events and circumstances. The stressful life events that precipitate an episode frequently grow out of difficult personal and family rela- tionships. The impact of these experiences depends on the mean- ings that people assign to them. People become depressed when they interpret events in a way that diminishes their sense of self- worth. Persistent interpersonal and cognitive problems also serve to maintain a depressed mood over an extended period of time and help it escalate to clinical proportions.

Biological Factors We have considered a number of social and psychological factors that contribute to the etiology of mood disorders. Biological factors

How do these self-defeating biases lead to the onset of de- pression? One cognitive approach to depression is focused on the importance of maladaptive schemas, which are general patterns of thought that guide the ways in which people perceive and interpret events in their environment. Schemas are enduring and highly or- ganized representations of prior experience. Although schemas may be latent—that is, not prominently represented in the person’s con- scious awareness at any given point in time—they are presumably reactivated when the person experiences a similar event. Depressive schemas increase the probability that the person will overreact to similar stressful events in the future ( Eberhart et al., 2011).

A similar view of cognitive vulnerability to depression has been described in terms of hopelessness (Alloy et al., 2009). Hopelessness refers to the person’s negative expectations about future events and the associated belief that these events cannot be controlled. According to this view, depression is associated with the expectation that desirable events probably will not oc- cur or that aversive events probably will occur regardless of what the person does. Following a negative life event, the probability that the person will become depressed is a function of the expla- nations and importance that the person ascribes to these events. These explanations are known as causal attributions.

Some people tend to explain negative events in terms of in- ternal, stable, global factors. This pattern has been called a depres- sogenic attributional style. For example, after failing an important exam, someone who uses this cognitive style would probably think that her poor performance was the result of her own inadequacies (internal), which she has recognized for a long time and which will persist into the future (stable), and which also are responsible for her failure in many other important tasks, both academic and oth- erwise (global). As in other cognitive views of depression, this kind of attributional style is not considered to be a sufficient cause of depression. It does represent an important predisposition to depres- sion, however, to the extent that people who use it are more likely to develop hopelessness if they experience a negative life event.

The importance of biased cognitive processing in risk for depression has been demonstrated persuasively in many labora- tory studies (Gotlib & Joormann, 2010). The cognitive prob- lems that depressed people experience seem to reflect primarily problems in the control of attention to, and memory for, negative emotional material. If depressed people begin to think unpleas- ant thoughts, they have difficulty inhibiting or disengaging from them (Joormann, 2010). For most people, adaptive strategies for mood regulation include the ability to change the content of their working memory and shift their thoughts away from distressing ruminations. Depressed people experience special problems in this regard. This perspective helps to explain why encounters with stressful life events may have a more lasting and detrimental impact on people who are vulnerable to depression.

Problems with the inhibition of negative thoughts have also been used to explain further the observation of gender differ- ences in the prevalence of depression (Nolen-Hoeksema et al., 2008). The manner in which a person responds to the onset of

mood disorders and suicide CHAPTER 5 123

(Bertelson, Harvald, & Hause, 1977). The concordance rates for bipolar disorders in MZ and DZ twins were .69 and .19, respec- tively. For depressive disorders, concordance rates for MZ and DZ twins were .54 and .24, respectively. The fact that the concor- dance rates were significantly higher for MZ than for DZ twins indicates that genetic factors are involved in the transmission of both bipolar and depressive mood disorders. The fact that the dif- ference between the MZ and DZ rate was somewhat higher for bipolar than for depressive disorders may suggest that genes play a more important role in bipolar disorders than in depressive dis- orders. Similar patterns of MZ and DZ concordance rates have been reported subsequently from twin studies of mood disorders conducted in Norway (Nes et al., 2007; Rekhborn-Kjennerud et al., 2010) and in England (McGuffin et al., 1996).

Twin studies also tell us that environmental factors influence the expression of a genetically determined vulnerability to depres- sion. The best evidence for the influence of nongenetic factors is the concordance rates in MZ twins, which consistently fall short of 100 percent. If genes told the whole story, MZ twins would always be concordant. Mathematical analyses have been used to estimate the relative contributions of genetic and environmen- tal events to the etiology of mood disorders. The results of these analyses are expressed in terms of heritability, which can range from 0 percent (meaning that genetic factors are not involved) to 100 percent (meaning that genetic factors alone are respon- sible for the development of the trait in question) (see Research Methods in Chapter 17). These analyses indicate that genetic fac- tors are particularly influential in bipolar disorders, for which the heritability estimate is 80 percent. Genes and environment con- tribute about equally to the etiology of major depressive disorder, in which the heritability estimate is close to 50 percent (McGuf- fin et al., 2003).

Searching for Specific geneS The family and twin studies indicate that genetic factors play an important role in the develop- ment of mood disorders. They have not, however, established exactly how that happens. It is difficult to identify specific genes involved in complex behavioral disorders because there is no straightforward pattern of inheritance. All of the evidence indicates that mood dis- orders are polygenic—that is, they are influenced by many different genes rather than a single gene—and each of these genes on its own only changes risk for the disorder by a small amount (Christoforou et al., 2011; Lewis et al., 2010; Shyn et al., 2011).

Several research strategies can be used to find evidence of a link between specific genes and the development of mood disor- ders (see Research Methods in Chapter 14). Various linkage and association studies have focused on both bipolar and depressive mood disorders. With the introduction of new gene-mapping techniques, our knowledge in this area is expanding dramatically, but the results remain inconclusive. Many findings have been re- ported, but specific genes and genetic risk factors have not been confirmed (Gershon et al. 2011). Preliminary reports regarding specific genes have often failed to replicate when they were tested by investigators in different laboratories.

are also influential in the regulation of mood. Various studies sug- gest that genetic factors are somehow involved in both depression and bipolar disorder, that hormonal abnormalities are regularly associated with depression, and that depression is associated with abnormalities in the activation of specific regions of the brain.

GENETiCS Genetic factors are clearly involved in the transmis- sion of mood disorders (Lau & Eley, 2010). Studies that support this conclusion also suggest that bipolar disorders are much more heritable than depressive disorders.

Twin STudieS The comparison of monozygotic (MZ) and dizygotic (DZ) twin pairs provides one test of the possible influ- ence of genetic factors (see Chapter 2). Several twin studies of mood disorders have reported higher concordance rates among MZ than among DZ twins (Kendler & Prescott, 2006).

One classic study used national twin and psychiatric regis- ters in Denmark to identify 110 pairs of same-sex twins in which at least one member was diagnosed as having a mood disorder

Separation from a spouse during a war can be extremely stressful. Whether the person becomes depressed is influenced by cognitive events as well as interpersonal skills that are used to cope with this difficult situation.

124 CHAPTER 5 mood disorders and suicide

not independent. Genetic factors apparently control the person’s sensitivity to environmental events (Caspi et al., 2010; Karg et al., 2011).

ThE NEurOENDOCriNE SYSTEM Various kinds of central ner- vous system events are associated with the connection between stressful life events and major depression. In the following sec- tions, we will consider evidence regarding hormones and specific regions of the brain. These are the biological phenomena that are closely associated with the social and psychological factors that we have described thus far. Cognitive and emotional events are implemented in these events (Miller & Keller, 2000). They are part of the process by which the brain communicates with the rest of the body and mobilizes activities in response to changes in the external environment.

The endocrine system plays an important role in regulating a person’s response to stress. Endocrine glands, such as the pituitary, thyroid, and adrenal glands, are located at various sites through- out the body (see Figure 2.4). In response to signals from the brain, these glands secrete hormones into the bloodstream. One important pathway in the endocrine system that may be closely related to the etiology of mood disorders is called the hypothalamic– pituitary–adrenal (HPA) axis. When the person detects a threat in the environment, the hypothalamus signals the pituitary gland to secrete a hormone called ACTH, which in turn modulates secre- tion of hormones, such as cortisol, from the adrenal glands into the bloodstream. Increased levels of cortisol help the person to prepare to respond to the threat by increasing alertness and delivering more fuel to muscles while also decreasing interest in other activities that might interfere with self-protection (such as sleeping and eating). This system is illustrated in Figure 5.4.

An association between the HPA axis and depression is indicated by evidence regarding the dexamethasone suppression test (DST), which has been used extensively to study endo- crine dysfunction in patients with mood disorders (Nemeroff, 1998a). Dexamethasone is a potent synthetic hormone. People who have taken a test dose of dexamethasone normally show a suppression of cortisol secretion because the hypothalamus is fooled into thinking that there is already enough cortisol cir- culating in the system. Some depressed people show a differ- ent response: Approximately half of depressed patients show a failure of suppression in response to the DST. After their symp- toms have improved, most of these patients exhibit a normal response on the DST. This pattern is consistent with the hy- pothesis that a dysfunction of the HPA axis may be involved in the development or maintenance of clinical depression, at least for some people (Stone, Lin, & Quarermain, 2008; Whybrow, 1997).

In what ways might endocrine problems be related to other causal factors? Several possibilities exist. In terms of the specific link between the endocrine system and the central nervous system, overproduction of cortisol may lead to changes in brain structure and function. At a more general level, hormone regulation may

The possibility of identifying specific genes that are involved in the development of mood disorders is very exciting. This knowledge might eventually enable mental health professionals to identify people who are vulnerable to a disorder before the on- set of overt symptoms. At the same time, however, two impor- tant cautions must be kept in mind regarding the complexity of the search for causes of mood disorders. One problem involves genetic heterogeneity. Within the general population, there may be more than one locus that contributes to the development of depression. Mood disorders may be linked to one marker within a certain extended family and to an entirely different marker in another family (Detera-Wadleigh & McMahon, 2004). Second, we also know that the environment plays an important role in the development of mood disorders. The onset of a mood disorder is determined by a combination of genetic and environmental risk factors that the individual experiences.

geneTic riSk and SenSiTiviTy To STreSS How do genetic factors and stressful life events interact to bring about depres- sion? One  demonstration of this effect was based on new genetic techniques that allow investigators to identify specific genes (Caspi et al., 2003). This investigation focused on the serotonin transporter (5-HTT) gene, which has been studied because several drugs that are used to treat depression have a direct im- pact on this particular neurotransmitter (see page 128). There are two alleles (long and short) for one particular region of the 5-HTT gene: The short allele (“s”) is associated with reduced efficiency of neural transmission in serotonin pathways. People who are homozygous for the “s” allele of the 5-HTT gene are at a particularly high risk for becoming clinically depressed if they experience stressful life events (see Figure 5.3). In the ab- sence of increased stress, the presence of this gene does not in- crease the person’s risk for depression. Both factors seem to be necessary. The effects of the environment and genetic factors are

figure 5.3 Combined Effects of Stress and Genetic vulnerability on risk for Depression Probability of onset of major depressive episode as a function of genotype for the serotonin transporter gene. *The short (“s”) allele is associated with lower efficiency compared to the long (“l”) allele. Source: Caspi et. al. Influence of Life Stress on Depression: Moderation by a Polymorphism in the 5-HTT Gene. Science. 2003 July 18, 2003; 18.

0.45

0.4

0.35

0.3

0.25

0.2

0.15

0.1

0.05

0 0 1 2 3 4

Number of Stressful Life Events

l/l

s/l

s/s

Genotype*

mood disorders and suicide CHAPTER 5 125

type might have motivational problems, such as an inability to work toward a pleasurable goal. Other areas of the PFC have been found to show abnormally elevated levels of activity in depressed people. These include the orbital PFC and the ventromedial PFC, areas of the brain that are important for determining a per- son’s responses to reward and punishment. More specifically, the orbital PFC inhibits inappropriate behaviors and helps the person ignore immediate rewards while working toward long-term goals. The ventromedial PFC is involved in the experience of emotion and the process of assigning meaning to perceptions. Overactivity in these regions of the brain might be associated with the pro- longed experience of negative emotion.

The anterior cingulate cortex (ACC) provides a connection between the functions of attention and emotion. It allows us to focus on subjective feelings and to consider the relation between our emotions and our behavior. For example, the ACC is acti- vated when a person has been frustrated in the pursuit of a goal, or when he or she experiences an emotion, such as sadness, in a situation where it was not expected. People suffering from ma- jor depressive disorder typically show decreased activation of the ACC ( Davidson et al., 2002). A reduction in ACC activity might be reflected in a failure to appreciate the maladaptive nature of prolonged negative emotions and a reduced ability to engage in more adaptive behaviors that might help to resolve the person’s problems.

The amygdala (see Figure 5.5), almond-sized nuclei near the tip of the hippocampus on each side of the brain, appear to be an

provide a process through which stressful life events interact with a genetically determined predisposition to mood disorder. Stress causes the release of adrenal steroids, such as cortisol, and steroid hormones play an active role in regulating the expression of genes (Gotlib et al., 2008).

BrAiN iMAGiNG STuDiES The newest tools in the search for biological underpinnings of mood disorders are those that al- low scientists to create detailed images of brain structures and to monitor ongoing brain functions in living patients (see Chapter 4 for a description of these procedures). The brain circuits that are involved in the experience and control of emotion are complex, centering primarily on the limbic system and its connections to the prefrontal cortex and the anterior cingulate cortex. Brain im- aging studies indicate that severe depression is often associated with abnormal patterns of activity as well as structural changes in various brain regions (Davidson et al., 2002; Gotlib & Ham- ilton, 2008). Some of these areas of the brain are illustrated in Figure 5.5. See Figure 2.3 for illustrations of the amygdala, hip- pocampus, and other structures involved in the limbic system.

Abnormal patterns of activation in regions of the prefrontal cortex (PFC) are often found in association with depression. This evidence has been collected using functional brain imaging proce- dures, such as PET and fMRI. Some areas show decreased activity, especially the dorsolateral prefrontal cortex on the left side of the brain. This area of the PFC is involved in planning that is guided by the anticipation of emotion. A person who has a deficit of this

figure 5.4 hormonal System Known as the hypothalamic–Pituitary– Adrenal (hPA) Axis The hypothalamic-pituitary-adrenal axis is activated in response to stress. Watch the Video The Hypothalamic-Pituitary-Adrenal (HPA) Axis on MyPsychLab Source: Based on Nemeroff, C. The Neurobiology of Depression. Scientific American. 1998; 278: 28–35.

Physiological changes supporting “fight–or– flight” responses

Adrenal gland

Anterior pituitary gland

Acth

Inhibitory signal

Stress

Hypothalamus

CRF

Bloodstream

Cortisol

Effects of CRF application to brain in animals

Decreased Increased

Eating Restless activity in familiar environments Sleeping Withdrawal in unfamiliar environments Reproductive activity

126 CHAPTER 5 mood disorders and suicide

Moreno, 2006). Our knowledge in this area began with the accidental discovery, during the 1950s, of several drugs that have the ability to alter people’s moods. The development of antide- pressant drugs stimulated research on several specific neurotrans- mitters that have been shown to be responsible for their effects. Most notable among these are serotonin, norepinephrine, and dopamine. Each neurotransmitter works in a broad set of path- ways connecting fairly specific brain locations.

Serotonin is the chemical messenger that is enhanced by medications, such as Prozac. It has a profound effect on a person’s mood, with higher levels being associated with feelings of serenity and optimism. Serotonin also plays an important role in areas of the brain that regulate sleep and appetite. Serotonin pathways in- clude connections involving the amygdala, the hypothalamus, and areas of the cortex. The beneficial effects of drugs such as Prozac (see the section on treatment of depression) provide the most con- vincing evidence for the argument that some type of malfunction in serotonin pathways is involved in the etiology of depression.

We know that the relation between neurotransmitters and depression is complex, and the specific mechanisms are not well understood. There may be more than 100 different neurotrans- mitters in the central nervous system, and each neurotransmitter is associated with several types of postsynaptic receptors. It seems unlikely that a heterogeneous disorder such as depression, which involves a dysregulation of many cognitive and emotional func- tions, will be linked to only one type of chemical messenger or only one loop in the brain’s circuitry. Current theories tend to

important part of the neural circuit involved in emotion (Canli, 2009). They are extensively connected to the hypothalamus. This system is responsible for monitoring the emotional significance of information that is processed by the brain and regulating so- cial interactions. Functional imaging studies have identified el- evated levels of resting blood flow and glucose metabolism in the amygdala among patients with major depressive disorder and bipolar disorder (Drevets, 2002). Higher metabolism rates are associated with more severe levels of depression. Patients who re- spond positively to treatment show a normalization of amygdala metabolism.

It is tempting to infer from this pattern that the increased activity reflected in images of the amygdala represents, at the neu- rochemical level of analysis, a reflection of the distorted cogni- tive functions that have been described by clinical psychologists in association with depression (Gotlib & Hamilton, 2008). Of course, this kind of speculation will need to be tested using more detailed research strategies in which specific cognitive processes are measured while brain activities are recorded in depressed and nondepressed people.

NEurOTrANSMiTTErS Communication and coordination of information within and between areas of the brain depend on neu- rotransmitters, chemicals that bridge the gaps between individual neurons (see Chapter 2). Over the past several decades, scientists have gathered a great deal of information concerning the neu- rochemical underpinnings of depression and mania (Delgado &

figure 5.5 Areas of the Brain involved in Depression Brain regions involved in emotion and mood disorders. Source: Davidson, Richard J., Diego Pizzagalli, Jack B. Nitschke, and Katherine Putnam. DEPRESSION: Perspectives from Affective Neuroscience. Annual Review of Psychology. 2002. 53:545–74. Copyright (c) 2002 by Annual Reviews. All rights reserved.

Orbital prefrontal cortex Ventromedial prefrontal cortex

Dorsolateral prefrontal cortex

Hippocampus

Amygdala

Anterior cingulate cortex

mood disorders and suicide CHAPTER 5 127

(yet obviously not the same as) those seen in depressed humans ( Lanfumey, Mongeau, & Cohen-Salmon, 2008). The animals de- velop deficits in motor activity, sleep, and eating behaviors. This type of stress-induced depression in laboratory rats produces vari- ous temporary effects on neurotransmitters, including changes in the concentration of norepinephrine, serotonin, and dopamine in the specific regions of the limbic system and the frontal cortex. Rats that show these neurochemical consequences following expo- sure to stress exhibit signs of depression. If the neurotransmitters are not depleted, the rats do not appear to be depressed. Further- more, administering antidepressant drugs to these animals has been shown to reverse or prevent the behavioral effects of uncon- trollable stress. Selective breeding experiments have been able to produce subtypes of rats that differ in their response to behavioral challenges (such as the forced swim test), as well as in their re- sponse to antidepressant medication (Ressler & Mayberg, 2007).

emphasize the interactive effects of several neurotransmitter sys- tems, including serotonin, norepinephrine, dopamine, and neu- ropeptides (short chains of amino acids that exist in the brain and appear to modulate the activity of the classic neurotransmitters) (Stockmeier, 2003; Thase, Ripu, & Howland, 2002).

integration of Social, Psychological, and Biological Factors We have considered a variety of social, psychological, and bio- logical factors that appear to be related to the causes of mood disorders. How can these factors be combined or integrated? One type of research that illustrates this point has employed an animal model of depression (see Research Methods). When laboratory animals are exposed to uncontrollable stress (such as a 15- minute forced swim in cold water from which they cannot escape), they frequently exhibit behavioral symptoms that are similar to

rESEarCh methods

Analogue Studies: Do Rats Get Depressed, and Why?

Many questions about the causes of psychopathology cannot be addressed using highly controlled labora-tory studies with human subjects. For example, does prolonged exposure to uncontrollable stress cause anxiety disor- ders? This kind of issue has been addressed using correlational studies with people who have the disorders in question, but ex- periments on these issues cannot be done with human subjects. For important ethical reasons, investigators cannot randomly assign people to endure conditions that are hypothesized to produce full-blown disorders, such as clinical depression. The best alternative is often to study a condition that is similar, or analogous, to the clinical disorder in question. Investigations of this type are called analogue studies because they focus on behaviors that resemble mental disorders—or isolated features of mental disorders—that appear in the natural environment.

Many analogue studies depend on the use of animal models of psychopathology, which have provided important insights regard- ing the etiology of conditions such as anxiety, depression, and schizophrenia (Fernando & Robbins, 2010). In the 1960s, Harry Harlow’s research demonstrated that rhesus monkey infants de- velop despair responses after separation from their mothers. The somatic symptoms exhibited by these monkeys—facial and vocal displays of sadness and dismay, social withdrawal, changes in ap- petite and sleep, and psychomotor retardation—were remarkably similar to many symptoms of clinical depression in humans.

This social separation model of depression has been used to ex- plore several important variables that may be involved in mood disorders. For example, infant monkeys who have extensive experience with peers and other adults are less likely to become depressed following separation from their mothers. The skills

that they learn through social exploration apparently allow them to cope more successfully with stress. The social separation model has also been used to explore neurochemical factors and mood disorders. Drug companies have used the model to evalu- ate the antidepressant effects of new drugs.

Some clinicians have argued that mental disorders, such as depres- sion, cannot be modeled in a laboratory setting, especially using animals as subjects. Cognitive symptoms—such as Beck’s depres- sive triad—cannot be measured with animals. Do monkeys feel guilty? Can rats experience hopelessness or suicidal ideas? But these symptoms are not necessarily the most central features of the disorder. Cross-cultural studies have shown that in some non-West- ern societies somatic symptoms are the most prominent symptoms of depression. Many of these aspects of mood disorder are seen in animals. The value of any analogue study hinges, in large part, on the extent to which the analogue condition is similar to the actual clinical disorder. Some models are more compelling than others.

Analogue studies have one important advantage over other types of research design in psychopathology: They can employ an experimental procedure. Therefore, the investigator can draw strong inferences about cause and effect. The main disadvan- tage of analogue studies involves the extent to which the results of a particular investigation can be generalized to situations out- side the laboratory. If a particular set of circumstances produced a set of maladaptive behaviors in the laboratory, is it reasonable to assume that similar mechanisms produce the actual clinical disorder in the natural environment? In actual practice, questions about the etiology of disorders, such as depression, will prob- ably depend on converging evidence generated from the use of many different research designs.

128 CHAPTER 5 mood disorders and suicide

Cathy also tended to think about herself in absolute and un- varying terms. During the course of therapy, she learned to rec- ognize this pattern and to substitute more flexible self-statements. Instead of saying to herself, “I am a hopeless introvert and will never be able to change,” she learned to substitute, “I am less comfortable in social situations than some other people, but I can learn to be more confident.”

The cognitive approach to treatment shares many features with behavioral approaches to intervention. Cognitive therapists are ac- tive and directive in their interactions with clients, and they focus most of their attention on their clients’ current experience. They also assume that people have conscious access to cognitive events: Our thinking may not always be rational, but we can discuss pri- vate thoughts and feelings. Another important aspect of the cogni- tive approach to treatment, and a characteristic that it shares with the behavioral perspective, is a serious commitment to the empiri- cal evaluation of the efficacy of treatment programs. Several studies have found that cognitive therapy is effective in the treatment of nonpsychotic depression (Hollon, Stewart, & Strunk, 2006).

iNTErPErSONAL ThErAPY Interpersonal therapy is another contemporary approach to the psychological treatment of depres- sion (Bleiberg & Markowitz, 2008; Weissman, Markowitz, & Klerman, 2000). It is focused primarily on current relationships, especially those involving family members. The therapist helps the patient develop a better understanding of the interpersonal problems that presumably give rise to depression and attempts to improve the patient’s relationships with other people by build- ing communication and problem-solving skills. Therapy sessions often include nondirective discussions of social difficulties and unexpressed or unacknowledged negative emotions, as well as role-playing to practice specific social skills.

ANTiDEPrESSANT MEDiCATiONS The types of medications that are used most frequently in the treatment of depressive mood disorders fall into four general categories: selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and “other,” more re- cently developed drugs. Among patients who respond positively to antidepressant medication, improvement is typically evident within four to six weeks, and the current episode is often resolved within 12 weeks (DePaulo & Horvitz, 2002). Medication is usu- ally continued for at least six to 12 months after the patient has entered remission in order to reduce the chance of relapse.

SelecTive SeroTonin reupTake inhibiTorS The selective serotonin reuptake inhibitors (SSRIs) were developed in the early 1980s and are now the most frequently used form of antide- pressant medication, accounting for more than 80 percent of all prescriptions written for that purpose (Hirschfeld, 2001). Unlike the original forms of antidepressant medication, which were dis- covered by accident, SSRIs were synthesized in the laboratories of pharmaceutical companies on the basis of theoretical speculation regarding the role of serotonin in the etiology of mood disorders.

This animal model illustrates the need to consider the in- teraction between biological and psychological phenomena. The data on stress-induced depression in rats suggest that neurochem- ical processes may be reactions to environmental events, such as uncontrollable stress in rats or severe life events in people. Psy- chological and biological explanations of depression are comple- mentary views of the same process, differing primarily in terms of their level of analysis.

Treatment Several procedures, both psychosocial and biological, have proved to be useful in the treatment of mood disorders. In the following pages we will examine some of the more prominent contempo- rary approaches to the treatment of major depression and bipolar disorder, as well as the research evidence on their usefulness.

Depressive Disorders Most psychological approaches to the treatment of depression owe some debt to psychodynamic procedures and Freud’s empha- sis on the importance of interpersonal relationships. According to Freud’s view, the primary goal of therapy should be to help the patient understand and express the hostility and frustration that are being directed against the self. These negative emotions are presumably rooted in dysfunctional relationships with other peo- ple. Freud also placed considerable emphasis on the apparently irrational beliefs that depressed people hold about themselves and their world. These cognitive factors are also emphasized by cogni- tive therapists.

Cognitive Therapy The cognitive model assumes that emotional dysfunction is in- fluenced by the negative ways in which people interpret events in their environments and the things that they say to themselves about those experiences. Based on the assumption that depres- sion will be relieved if these maladaptive schemas are changed, cognitive therapists focus on helping their patients replace self- defeating thoughts with more rational self-statements (Dobson, 2008; Garratt et al., 2007).

A specific example may help illustrate this process. Consider the case of Cathy, the depressed attorney whom we introduced at the beginning of the chapter. Cathy focused a great deal of attention on relatively minor negative events at work, blaming herself for anything other than a perfect performance. Her thera- pist helped her to recognize that she was engaging in a pattern of cognitive distortion that has been labeled “selective abstrac- tion.” Taking a detail out of context, she would invariably ignore those aspects of her performance that refuted the conclusion that she was professionally incompetent. Her therapist helped her overcome these tendencies by teaching her to question her conclusions and to develop more objective ways of evaluating her experiences.

mood disorders and suicide CHAPTER 5 129

TriCYCLiCS The tricyclics antidepressants (TCAs), such as imipramine (Tofranil) and amitriptyline (Elavil), have been in relatively widespread use since the 1950s, but their use has de- clined since the introduction of the SSRIs because they have more side effects. Common reactions include blurred vision, con- stipation, drowsiness, and a drop in blood pressure. The TCAs af- fect brain functions by blocking the uptake of neurotransmitters (especially norepinephrine) from the synapse. Several controlled double-blind studies indicate that TCAs benefit many depressed patients, although improvements might not be evident until two or three weeks after the beginning of treatment (Thase, 2006). The several different kinds of tricyclic medication vary in potency and side effects, but they are generally equal in terms of effec- tiveness. Comparisons of TCAs and SSRIs indicate that they are approximately equal in terms of success rates, with positive re- sponses being shown by 50 to 60 percent of depressed patients (Schulberg et al., 1999).

MONOAMiNE OxiDASE iNhiBiTOrS The antidepressant ef- fects of monoamine oxidase inhibitors (MAOIs), such as phen- elzine (Nardil), were discovered at about the same time as those of the tricyclic drugs. These drugs have not been used as exten- sively as tricyclics, however, primarily for two reasons. First, pa- tients who use MAOIs and also consume foods containing large amounts of the compound tyramine, such as cheese and choco- late, often develop high blood pressure. Second, some early em- pirical evaluations of antidepressant medications suggest that MAOIs are not as effective as tricyclics.

More recent studies have shown that MAO inhibitors are in- deed useful in the treatment of depressed patients (Thase, 2006). They can be used safely when the patient avoids foods such as

There are many specific types of SSRIs (see Table 5.3). Controlled outcome studies indicate that Prozac and other SSRIs are about as effective as traditional forms of antidepressant medication (von Wolff et al., 2013).

The SSRIs inhibit the reuptake of serotonin into the pre- synaptic nerve ending and thus promote neurotransmission in serotonin pathways by increasing the amount of serotonin in the synaptic cleft. They are called “selective” because they seem to have little if any effect on the uptake of norepinephrine and do- pamine. Nevertheless, the SSRIs are not entirely selective, in the sense that some of them do block reuptake of other neurotrans- mitters. They also vary in the potency with which they block se- rotonin reuptake. Their effectiveness in treating depression does not seem to be directly related to either the extent to which a particular SSRI is selective with regard to serotonin or its potency in blocking serotonin reuptake (Pallanti & Sandner, 2007).

The SSRIs are typically considered to be easier to use than other antidepressant drugs. They also have fewer side effects (such as constipation and drowsiness), and they are less dangerous in the event of an overdose. This does not mean, of course, that they are completely without side effects (see Critical Thinking Mat- ters on page 131). Some patients experience nausea, headaches, and sleep disturbances, but these symptoms are usually mild and short term. The most troublesome side effects associated with SSRIs are sexual dysfunction and weight gain. The rate of de- creased sexual desire and orgasmic dysfunction may be as high as 50 percent among both men and women taking SSRIs. Weight changes in response to SSRIs vary in relation to length of treat- ment. Many patients experience an initial weight loss, but most regain this weight after six months. Those who continue to take the medication may gain an average of 20 pounds.

table 5.3 Medications for Depressive Mood Disorders Drug Class Generic Name (Trade Name) Mode of Action

Selective serotonin Fluoxetine (Prozac) Block 5-HT reuptake

reuptake inhibitors (SSRIs) Paroxetine (Paxil)

Sertraline (Zoloft)

Citalopram (Celexa)

Fluvoxamine (Luvox)

Tricyclic antidepressants Amitriptyline (Elavil) Block reuptake of 5-HT

(TCAs) Clomipramine (Anafranil) and norepinephrine

Imipramine (Tofranil)

Monoamine oxidase inhibitors (MAOIs)

Phenelzine (Nardil) Deactivate enzyme that breaks down monoamines

Other antidepressants Trazodone (Desyrel) Block 5-HT reuptake and block 5-HT receptors

Bupropion (Wellbutrin) Block norepinephrine and dopamine reuptake

Venlafaxine (Effexor) Block reuptake of 5-HT and norepinephrine

Note: 5-HT is serotonin.

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people recover from episodes of mania and depression and also on a long-term maintenance basis to reduce the frequency of future episodes (Geddes et al., 2004). Antidepressant medications are sometimes used, usually in combination with a mood stabilizer, for the treatment of bipolar patients (Fountoulakis et al., 2008). Clinicians must be cautious, however, because antidepressants can sometimes trigger a switch from depression into a hypomanic or manic episode.

LiThiuM An extensive literature indicates that the salt lithium carbonate is an effective form of treatment in the alleviation of manic episodes, and it remains the first choice for treating bipolar disorders. It is also useful in the treatment of bipolar patients who are experiencing a depressive episode. Perhaps most importantly, bipolar patients who continue to take lithium between episodes are significantly less likely to experience a relapse (Bauer & Mitchner, 2004).

Unfortunately, there are also some limitations associated with the use of lithium. Many bipolar patients, perhaps 40 percent, do not improve when they take lithium (Mendlewicz, Souery, & Rivelli, 1999). Nonresponse is particularly common among rapid cycling patients, those who exhibit a mixture of manic and de- pressed symptoms, and those with comorbid alcohol abuse. Compliance with medication is also a frequent problem; at least half the people for whom lithium is prescribed either fail to take it regularly or stop taking it against their psychiatrist’s advice. The main reasons that patients give for discontinuing lithium involve its negative side effects, including nausea, memory problems, weight gain, and impaired coordination.

ANTiCONvuLSANT MEDiCATiONS Often, bipolar patients who do not respond to lithium are prescribed anticonvulsant drugs, particularly carbamazepine (Tegretol) or valproic acid (Depakene) (Reinares et al., 2013). Outcome data suggest that slightly more than 50 percent of bipolar patients respond posi- tively to these drugs. Like lithium, carbamazepine and valproic acid can be useful in reducing the frequency and severity of relapse, and they can be used to treat acute manic episodes. Valproic acid may be more effective than lithium for the treat- ment of rapid cycling bipolar patients and those with mixed symptoms of mania and depression in a single episode (Gadde & Krishman, 1997). Common side effects include gastrointestinal distress (nausea, vomiting, and diarrhea) and sedation.

PSYChOThErAPY Although medication is the most important method of treatment for bipolar disorders, psychotherapy can be an effective supplement to biological intervention. Both cognitive therapy and interpersonal therapy have been adapted for use with bipolar disorders. Cognitive therapy can address the patient’s re- actions to stressful life events as well as his or her reservations about taking medication (Craighead & Miklowitz, 2000).

A variation on interpersonal therapy, known as interper- sonal and social rhythm therapy has been developed for use with

cheese, beer, and red wine. In addition, MAOIs are now widely used in the treatment of certain anxiety disorders, especially ago- raphobia and panic attacks (see Chapter 6).

ThE EFFiCACY OF PSYChOThErAPY AND MEDiCATiON Considerable time and energy have been devoted to the evaluation of psychological and pharmacological treatments for depression. The bottom line in this lengthy debate—based on extensive reviews of the research literature—is that both cogni- tive therapy and antidepressant medication are effective forms of treatment for people who suffer from depression (Hollon, Thase, & Markowitz, 2002). This is true for people with major depres- sive disorder as well as persistent depressive disorder. In actual practice, many experts recommend treatment with a combination of psychotherapy and medication (Kupfer & Frank, 2001; Simon et al., 2006).

Carefully controlled treatment outcome studies indicate that medication and psychotherapy are approximately equivalent in the treatment of people who are chronically depressed. Either form of treatment is a reasonable choice for people suffering from depression. Recent evidence indicates that the combination of psychotherapy and antidepressant medication often leads more quickly to a remission of symptoms than either form of treatment alone (Cuijpers et al., 2012).

Bipolar Disorders Treatment of bipolar disorders has also focused on the combined use of medication and psychotherapy. A variety of mood- stabilizing drugs are employed with bipolar patients. They are used to help

© Barbara Smaller/The New Yorker Collection/www.cartoonbank.com

mood disorders and suicide CHAPTER 5 131

resolve interpersonal problems effectively. Regulation of sleep and work patterns is also important. This therapy program is em- ployed in combination with the long-term use of mood stabiliz- ing medication.

Current evidence indicates that the combination of psychother- apy and medication for the treatment of bipolar disorder is more beneficial than medication alone (Miklowitz et al., 2007). There is an obvious need for more extensive research on the effectiveness of various types of psychosocial treatment for bipolar disorders.

bipolar patients (Frank, 2005). It is based on the recognition that a repeated episode of either mania or depression is often precip- itated by one of the following factors: stressful life events, dis- ruptions in social rhythms (the times of day in which the person works, sleeps, and so on), and failure to take medication. Special emphasis is placed on monitoring the interaction between symp- toms (especially the onset of hypomanic or manic episodes) and social interactions. Therapists help patients learn to lead more orderly lives, especially with regard to sleep–wake cycles, and to

CriTiCal Thinking matters

Do Antidepressant Drugs Cause Violent Behavior?

Extensive media attention has been devoted to the sugges-tion that some of the SSRIs can increase the risk of violent and suicidal behavior. Several dramatic cases have been discussed at great length. One example is Chris Pittman, who was found guilty in 2005 of killing his paternal grandparents with a shotgun when he was 12 years old. No one questioned the basic facts of the case. Pittman admitted that he blasted his grandparents with a shotgun while they were sleeping. He then set their house on fire and fled the area. After he was caught, his defense team mounted what some court observers called the Zoloft defense, claiming that the murders were triggered by the boy’s reaction to antidepressant medication that he had been taking for several days before the murders (see Chapter 18 for a discussion of the insanity defense). Prosecutors argued, on the other hand, that he killed his grandparents because he was an- gry after they disciplined him for fighting with a younger student on the school bus earlier that day. In other words, his motivation did not involve a mental disorder or a reaction to medication. Pittman was tried as an adult, convicted by a jury, and sentenced to 30 years in prison.

Tragic public cases such as this one generate strong opinions on both sides. Magazines and Web sites are filled with warnings about the dangers of treating children and adolescents with SSRIs, some more extreme than others. Many psychiatrists have responded by noting the beneficial effects that antidepressant medication can have for young people. Clearly, parents should be warned about negative side effects that are sometimes asso- ciated with drugs such as Zoloft, but should they be frightened to the point that they avoid using one of the most effective forms of treatment for mood disorders? Critical thinking must prevail.

One important issue in this ongoing debate is the need for empirical evidence. Do SSRIs cause a significant increase in the risk of violence and suicide? Millions of people take antidepres- sant medication. Many depressed people commit suicide, in spite of the best efforts to treat their condition. The fact that one person committed suicide or any other violent crime while

taking a specific drug does not provide convincing evidence that the drug caused the person to engage in that behavior. The question is whether people taking Zoloft are more likely to be suicidal or violent than other (similarly) depressed people who are being given another form of treatment. The data suggest that SSRI treatment does not increase risk of suicidal behavior, but the issue has not been closed entirely (Breggin, 2004; Gibbons et al., 2007). In the absence of better evidence, the U.S. Food and Drug Administration (FDA) requires that a warn- ing be printed on the label when Zoloft (and some other SSRIs) is prescribed for children, including the following statement:

Families and caregivers of pediatric patients being treated with antidepressants . . . should be alerted about the need to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and the other symptoms described above, as well as the emergence of suicidality.

The legal implications of these findings remain ambiguous. Most forms of antidepressant medication are capable of trigger- ing manic episodes in people who are depressed (Goldberg & Truman, 2003), and the symptoms of mania sometimes include hostility and aggression. Does that mean that SSRIs can cause someone to become homicidal or suicidal? When people come out of a period of depression and their mood is lifting, they also experience an increase in energy. For many years, experts have recognized that this period of time can be especially dangerous for people who have harbored serious thoughts of violence. If they decide to act on those impulses, is it the pill’s fault? Is the person no longer responsible for his or her behavior?

While the public does need to be warned about side effects that can be associated with medication, it is also irresponsible to ex- aggerate or distort that evidence. People who are frightened do not make well-informed decisions. In fact, the risks of medication side effects must be balanced against the risks associated with failing to treat a potentially lethal condition such as depression (Brent, 2004).

132 CHAPTER 5 mood disorders and suicide

and cognitive therapy. Nevertheless, it remains a viable and legitimate alternative for some severely depressed patients, es- pecially those who are so suicidal that they require constant supervision to prevent them from harming themselves. As al- ways, the risks of treatment must be carefully weighed against those associated with allowing the disorder to follow its natu- ral course.

Seasonal Mood Disorders The observation that changes in seasons can help bring on episodes of mood disorder leads to the relatively obvious impli- cation that some patients might respond to manipulations of the natural environment. For centuries, physicians have prescribed changes in climate for their depressed clients (Wehr, 1989). The prominent French psychiatrist Jean Esquirol (1772–1840) reportedly advised a patient whose depression appeared when the days grew shorter to move from Belgium to Italy during the winter.

Modern light therapy was introduced in the 1980s. Typical treatment involves exposure to bright (2,500 lux), broad- spectrum light for one to two hours every day. Some patients also respond positively to shorter periods (30 minutes) of high- intensity (10,000 lux) light. This high-intensity light is roughly equivalent to the amount of light that would be generated by a 750-watt spotlight focused on a surface 1 square meter in area. The light source—most often a rectangular box containing fluo- rescent ceiling fixtures—must be placed close to the patient at eye level. Improvement in the person’s mood is often seen within two to five days (Golden et al., 2005).

Outcome studies have found that light therapy is an effective form of treatment for seasonal affective disorder, with outcome being roughly equivalent to the use of standard antidepressant medication (Lam et al., 2006). The combination of light therapy with cognitive therapy may be more effective than either form of treatment alone (Rohan et al., 2007). Many patients with sea- sonal affective disorders do respond well to light therapy, and it is considered by many clinicians to be a useful approach to this dis- order. It is not exactly clear why or how light therapy works, but the process may help the body to normalize circadian rhythms, which regulate processes such as hormone secretion (Whybrow, 1997).

Suicide An Admiral’s Suicide

Admiral Jeremy (Mike) Boorda was the highest ranking officer in the U.S. Navy when, at the age of 56, he committed suicide (Thomas, 1996). He was married and the father of four children. Boorda was the first person in the history of the Navy to rise from the enlisted ranks to become chief of naval operations. Although his record of leadership was widely admired by both fellow

Electroconvulsive Therapy The procedure known as electroconvulsive therapy (or ECT) has proved beneficial for many patients suffering from mood disorders (see Chapter 3 for a review of the background of ECT). Electroconvulsive therapy is typically administered in an inpatient setting and consists of a series of treatments given three times a week for two to seven weeks (Abrams, 2002). Many patients show a dramatic improvement after six to eight sessions, but some require more. In current clinical practice, muscle relaxants are always administered before a patient re- ceives ECT. This procedure has eliminated bone fractures and dislocations that were unfortunate side effects of techniques used many years ago. The electrodes can be placed either bi- laterally (on both sides of the head) or unilaterally (at the front and back of the skull on one side of the patient’s head). Unilat- eral placement on the nondominant hemisphere (the right side of the head for right-handed people) may minimize the amount of post-seizure memory impairment, but it may also be less effective.

Although how ECT works remains largely a mystery, em- pirical studies have demonstrated that it is an effective form of treatment for severely depressed patients (Khalid et al., 2008). Reservations regarding the use of ECT center around widely publicized, although infrequent, cases of pervasive and persistent memory loss. Reviews of the research evidence in- dicate that ECT-induced changes in memory and other cog- nitive functions are almost always short-lived, and ECT does not induce loss of neurons or other changes in brain structure (Lisanby, 2007).

No one denies that ECT is an invasive procedure that should usually be reserved for patients who have been re- sistant to other forms of intervention, such as medication

Electroconvulsive therapy is an effective form of treatment for severely depressed patients. It should be considered for people who do not im- prove with psychotherapy or antidepressant medication.

mood disorders and suicide CHAPTER 5 133

restore morale and improve public confidence in the Navy. The Newsweek probe threatened to negate all of those efforts. Did his death represent a personal sacrifice for the military service that he loved and to which he had devoted 40 years of his life? These dif- ficult questions illustrate the challenges faced by clinicians, who must try to understand suicide so that they can more effectively prevent it.

Aides said that Admiral Boorda did not show any signs of being depressed, even on the morning that he died. Nor were there any indications of substance abuse or other mental disor- ders. In this respect, Boorda’s situation was unusual. Although many people who commit suicide do not appear to be depressed, and psychopathology doesn’t explain all suicidal behavior, there is undoubtedly a strong relationship between depression and self-destructive acts. The available evidence suggests that at least 50 percent of all suicides occur as a result of, or in the context of, a primary mood disorder (Nock et al., 2012). Moreover, the risk of completed suicide is much higher among people who are clinically depressed than it is among people in the general population. Follow-up studies consistently indicate that 15 to 20 percent of all patients with mood disorders will eventually kill themselves (Hawton et al., 2013). Thus, it seems reasonable to conclude that there is a relatively close link between suicide and depression.

Classification of Suicide Common sense tells us that suicide takes many forms. DSM-5 does not address this issue; rather, it lists suicidal ideation (thoughts of suicide) only as a symptom of mood disorders. Cli- nicians and social scientists have proposed a number of systems for classifying subtypes of suicide, based on speculation regarding different motives for ending one’s own life. Therefore, in contrast to the principles that were followed in creating DSM-5, classifica- tion systems for suicide are based on causal theories rather than descriptive factors.

The most influential system for classifying suicide was originally proposed in 1897 by Émile Durkheim (1858–1917), a French sociologist who is one of the most important figures in the history of sociology (Coser, 1977). In order to appreciate the nature of this system, you must understand Durkheim’s ap- proach to studying social problems. Durkheim was interested in “social facts,” such as religious groups and political parties, rather than the psychological or biological features of particu- lar individuals. His scientific studies were aimed at clarifying the social context in which human problems appear, and they were based on the assumption that human passions and ambi- tion are controlled by the moral and social structures of society. One of his most important scientific endeavors was a compari- son of suicide rates among various religious and occupational groups.

officers and prominent politicians, he had recently been the subject of journalistic scrutiny. Questions had been raised about whether Boorda had legitimately earned two medals that he dis- played on his uniform for several years (small Vs that are awarded to people who have shown valor in combat). These public sym- bols of heroism are a source of considerable status, especially among professional military people. Boorda had stopped wear- ing the medals after the issue was initially raised, but some mem- bers of the media had decided to pursue the issue further. On the morning of his death, Boorda was told that reporters from Newsweek magazine wanted to ask him some more questions about his justification for wearing these medals. He never met with them. Telling other officers that he was going home for lunch, Boorda went home and shot himself in the chest with a .38 revolver.

Why would such a successful person choose to end his own life? Suicide is an extremely personal, private, and complicated act. We will never know exactly why Admiral Boorda killed himself, but the circumstances surrounding his death are consistent with a number of facts about suicide. The highest rate of suicide in the United States is found among white males over the age of 50. Within this group, men who have been occupationally success- ful are more likely to commit suicide, especially if that success is threatened or lost. Notes that the admiral left for his wife and for Navy personnel indicated that he could no longer face the public dishonor that might result from Newsweek’s investigation. Escape from psychological suffering is often a significant motive in suicide. Did Boorda commit suicide primarily to end his own subjective distress? Or was his death intended to avoid bringing disgrace to the Navy, which had been plagued by other scandals in recent years? When he was appointed chief of naval operations, several months before his death, it had been hoped that he would

This man is receiving light therapy for the treatment of seasonal affective disorder.

134 CHAPTER 5 mood disorders and suicide

or her existence. This type of suicide was mentioned only briefly by Durkheim, who thought that it was extremely uncommon.

Durkheim believed that egoistic and anomic suicide were the most common types of suicide in Western industrial societies. Although he distinguished between these two dominant forms, he recognized that they were interconnected and could operate together. Some people may become victims of both diminished integration and ineffective regulation.

Durkheim’s system for classifying types of suicide has re- mained influential, but it does have some limitations (Leenaars, 2004; Stack, 2004). For example, it does not explain why one person commits suicide while other members of the same group do not. All the people in the group are subject to the same social structures. Another problem with Durkheim’s system is that the different types of suicide overlap and may, in some cases, be dif- ficult to distinguish. If the system is used to describe individual cases of suicide, such as that of Admiral Boorda, would clinicians be likely to agree on these subtypes? We are not aware of any at- tempts to evaluate the reliability of such judgments, but it might be quite low.

NONSuiCiDAL SELF-iNjurY Some people deliberately harm themselves without trying to end their own lives. The most fre- quent forms of nonsuicidal self-injurious behaviors involve cut- ting, burning, or scratching the skin, usually in a place where the wounds and resulting scars can easily be concealed from others (Levenkron, 2006). Nonsuicidal self-injury must be dis- tinguished from fashion trends, such as piercing and tattooing. People get tattoos and pierce various parts of their bodies with ornaments and jewelry because the effect on their appearance is considered stylish or distinctive. These activities are accomplished

In his book Suicide, Durkheim (1897/1951) argued that the rate of suicide within a group or a society would increase if lev- els of social integration and regulation are either excessively low or excessively high. He identified four different types of suicide, which are distinguished by the social circumstances in which the person is living:

• Egoistic suicide (diminished integration) occurs when people become relatively detached from society and when they feel that their existence is meaningless (Maimon & Kuhl, 2008). Egoistic suicide is presumably more common among groups such as people who have been divorced and people who are suffering from mental disorders. The predominant emotions associated with egoistic suicide are depression and apathy.

• Altruistic suicide (excessive integration) occurs when the rules of the social group dictate that the person must sacrifice his or her own life for the sake of others. One example is the former practice in some Native American tribes of elderly persons voluntarily going off by themselves to die after they felt they had become a burden to others.

• Anomic suicide (diminished regulation) occurs following a sudden breakdown in social order or a disruption of the norms that govern people’s behavior. Anomic suicide ex- plains increased suicide rates that occur following an eco- nomic or political crisis or among people who are adjusting to the unexpected loss of a social or occupational role. The typical feelings associated with anomie (a term coined by Durkheim, which literally means “without a name”) are an- ger, disappointment, and exasperation.

• Fatalistic suicide (excessive regulation) occurs when the circumstances under which a person lives become un- bearable. A slave, for example, might choose to commit suicide in order to escape from the horrible nature of his

Distinctions among Durkheim’s types of suicide can be difficult to make. Do the motives of suicide bombers reflect a breakdown of social order? Or does their violent behavior represent a personal sacrifice for the sake of their society?

mood disorders and suicide CHAPTER 5 135

Why do some people deliberately hurt themselves, often disfiguring their own bodies? Several different explanations have been reported (Klonsky, 2007). For some people, cutting is a way to punish the self and is a reflection of frustration and anger. In other cases, the person uses self-inflicted pain in an effort to combat extended periods of dissociation and feelings of empti- ness that accompany the absence of family members and friends. But the most commonly reported mechanism suggests that self- injury becomes a maladaptive way to regulate intense, negative emotional states. Episodes of self-injurious behavior are typically preceded by strong feelings of anxiety, anger, frustration, or sad- ness. These emotions are quickly diminished once the cutting has begun, and the person experiences relief. The final phase of the sequence involves the experience of shame or guilt when the episode is completed and the person reflects on what they have done.

Frequency of Suicide In the United States and Canada, the annual rate of completed suicide across all age groups has averaged approximately 12 peo- ple per 100,000 population for many years (Goldsmith, 2001). More than 35,000 people in the United States kill themselves every year. In 2010, more people died by suicide than in car acci- dents (Center for Disease Control and Prevention, 2013). Suicide rates vary as a function of many factors, including age, gender, and socioeconomic status. The suicide rate increased among ado- lescents from the 1970s through the mid 1990s, corresponding to an increase in the prevalence of depression and a decrease in the average age of onset for depression. More recently, suicide rates have increased by nearly 30 percent among middle-aged Americans (see Figure 5.6). Rates among other age groups either fell or remained steady. Suicide has become the third leading cause of death for people between the ages of 15 and 24, and it is the eighth leading cause of death in the general population (Kochanek et al., 2004).

Suicide attempts are much more common than are completed suicides. The ratio of attempts to completed suicides in the general population is approximately 10 to 1; among adolescents, the ratio

in spite of the initial pain that the person must endure. In con- trast, people who engage in nonsuicidal self-injury do it because the pain serves a useful purpose for them regardless of its impact on their appearance. Watch the Video Mary: Non-Suicidal Self Injury on MyPsychLab

This problem can take many different forms and be associ- ated with various kinds of mental disorders. Deliberate self-harm is listed in DSM-5 as one of the symptoms of borderline person- ality disorder (see Chapter 9), but it also occurs among people suffering from other disorders, especially substance use disorders, eating disorders, depression, and posttraumatic stress disorder. Approximately 4 percent of people in the general population re- port that they have engaged in nonsuicidal self-injurious behav- iors, and many of them would not qualify for the diagnosis of any specific disorder (Klonsky, Oltmanns, & Turkheimer, 2003; Nock & Kessler, 2006). Sometimes, deliberate self-harm is itself the primary problem.

Self-injury is often a maladaptive way to regulate intense, negative emotions.

figure 5.6 Suicide rates Across the Lifespan Suicide rates per 100,000 population by five-year group, race, and gender, United States, 1991. Source: Moscicki, E. K. (1995), “Epidemiology of Suicidal Behavior.” Suicide and Life-Threatening Behavior, 25: 22–35. Copyright © 1995 The American Association for Suicidology. Reprinted by permission of John Wiley & Sons, Inc.

Ra te

s pe

r 1 00

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Five-year age groups 10–14

15–19 20–24

25–29 30–34

35–39 40–44

45–49 50–54

55–59 60–64

65–69 70–74

75–79 80–84

85+

20

0

40

60

80

Black women

White women

Black men

White men

136 CHAPTER 5 mood disorders and suicide

1996). According to this perspective, psychological pain is pro- duced by prolonged frustration of psychological needs. Most im- portant are the needs for affiliation and competence. People who view themselves as having failed in these domains—those who are low in belongingness or high in burdensomeness—will expe- rience intense negative emotional states, such as shame, guilt, an- ger, and grief. For some people, suicide appears to offer a solution or a way to end their intolerable distress.

The desire to die is linked closely to social isolation and the belief that one has become a burden to others. But most people who experience these problems do not go on to attempt suicide. That action requires that the desire to end one’s own life must be accompanied by the ability to enact lethal self-injury. Fear of death is one of our strongest emotions, and self-preservation is a powerful motive. Fortunately, these instincts protect most people in their worst emotional moments. The second component of the interpersonal-psychological theory holds that people who make lethal suicide attempts often work their way up to the act gradu- ally (Joiner, 2005). This process may involve repeated nonsuicidal self-injurious behaviors, which allow the person to habituate to pain and fear of death. Previous suicide attempts, those that do not result in death, may also set the stage for a final lethal at- tempt. The interpersonal-psychological theory holds that death by suicide requires a combination of both the desire to die and the ability to inflict lethal harm to the self, which is frequently ac- quired through previous experience. Research evidence provides considerable support for this proposal (Van Orden et al., 2008).

BiOLOGiCAL FACTOrS Studies of the connection between neurotransmitters and suicide have focused primarily on reduced levels of serotonin, which might be related to poor impulse con- trol as well as increased levels of violent and aggressive behavior

is closer to 100 to 1 (Hendin, 1995). There are important gender differences in rates of attempted suicide versus rates of completed suicide. Females aged 15 to 19 years make three times as many suicide attempts as males. Completion rates, however, are four times higher among males (Spirito & Esposito-Smythers, 2006). The difference in fatalities may be due, in part, to the methods employed. Men and boys are more likely to use violent and lethal methods such as firearms and hanging, whereas women and girls are more likely to take an overdose of drugs, which may allow time for discovery and interventions by other people.

The risk of completed suicide is highest among older people. Suicide rates have increased among middle-aged adults in recent years, but the highest rates are still found among older people, especially older white men. Although suicide attempts are most common among younger people, with most being made by those younger than 30, the proportion of suicide attempts that end in death is particularly high among the elderly. It is not clear whether this pattern should be attributed to a difference in method or to decreased physical resilience.

Suicides in the U.S. military increased dramatically after more than a decade of combat in Iraq and Afghanistan (Kuehn, 2010). In 2012, the number of active duty and reserve troops who committed suicide exceeded the number of American com- bat deaths in Afghanistan. Many of these deaths reflect the enor- mous stress associated with life in a combat zone, but a significant proportion of the people who took their own lives had not been deployed. The challenges faced by military personnel obviously include depression, posttraumatic stress, and substance use disor- ders, all of which are associated with an increase in suicide rates. But they also extend to problems associated with long-term sepa- rations from family members, financial problems, and the chal- lenges associated with return to civilian life (Black et al., 2011).

Causes of Suicide Many factors contribute to suicidal behavior. In the following discus- sion, we consider some of the variables that operate at the level of the individual person—psychological and biological considerations— and are associated with suicidal behavior. We also summarize some contemporary research on social factors that are related to suicide.

PSYChOLOGiCAL FACTOrS Many experts have argued that psychological events lie at the core of suicidal behavior (Joiner, 2005). Social factors may set the stage for self-destructive acts, but events taking place within the person’s mind are most im- mediately responsible for determining whether a particular indi- vidual will attempt to end his or her own life. Prominent among these events are intense emotional distress and hopelessness. An outline of several psychological variables that are commonly asso- ciated with suicide is presented in Common Elements of Suicide.

The interpersonal-psychological theory of suicidal behavior maintains that suicidal behavior represents an attempt to escape from unbearable psychological pain (Joiner, 2005; Schneidman,

Brain injuries may increase the risk of suicide, particularly among military combat veterans and athletes in violent sports. Junior Seau, one of the most honored football players of his generation, retired from the NFL in 2009. He committed suicide in 2012 at the age of 43. An autopsy showed that he suffered from chronic traumatic encephalopathy.

mood disorders and suicide CHAPTER 5 137

Genes associated with various neurotransmitter systems, especially serotonin, influence the development of impulsive personality traits, and suicide appears to be an especially likely outcome when a person inherits a predisposition to both psychopathology and im- pulsive or violent behavior. Genetic factors moderate the impact of environmental factors, such as stressful life events and childhood abuse, on suicidal behavior (Brezo, Klempan, & Turecki, 2008).

SOCiAL FACTOrS Durkheim (1897/1951) believed that suicide rates had increased during the nineteenth century because of an erosion of the influence of traditional sources of social integration and regulation, such as the church and the family. Social structures do represent one important consideration with regard to suicide

(Currier & Mann, 2008; Joiner, Brown, & Wingate, 2005). Ana- logue studies with animals have found that lesions resulting in serotonin dysfunction lead to increases in aggression and failure to inhibit responses that were previously punished. Difficulty in regulating serotonin systems has been found among people who attempted suicide, and it has also been found among people who have shown other types of violent and aggressive behavior.

Twin studies and adoption studies have found that genetic fac- tors are involved in the transmission of mood disorders. Do genes contribute to the risk for suicide indirectly by increasing the risk for mental disorders, such as depression, schizophrenia, and sub- stance abuse? Or is there a more direct contribution of genetic factors to self-destructive behavior? The answer appears to be yes.

Common Elements of Suicide

Most people who kill themselves are suffering from some form of mental disorder, such as depression, post-traumatic stress disorder, a substance use disorder, or schizophrenia (Jamison, 1999). No single explanation can account for all self-destructive behavior, but the following list includes features that are frequently associated with completed suicide (Schneidman, 1996). 1. The common purpose of suicide is to seek a solution. Suicide

is not a pointless or random act. To people who think about ending their own lives, suicide represents an answer to an otherwise insoluble problem or a way out of some unbear- able dilemma. It is a choice that is somehow preferable to another set of dreaded circumstances, emotional distress, or disability, which the person fears more than death. Attrac- tion to suicide as a potential solution may be increased by a family history of similar behavior. If someone else whom the person admired or cared for has committed suicide, then the person is more likely to do so.

2. The common goal of suicide is cessation of consciousness. People who commit suicide seek the end of conscious experience, which to them has become an endless stream of distressing thoughts with which they are preoccupied.

3. The common stimulus (or information input) in suicide is unbearable psychological pain. Excruciating negative emo- tions—including shame, guilt, anger, fear, and sadness—fre- quently serve as the foundation for self-destructive behavior.

4. The common stressor in suicide is frustrated psychological needs. People with high standards and expectations are es- pecially vulnerable to ideas of suicide when progress toward these goals is suddenly frustrated. People who attribute fail- ure or disappointment to their own shortcomings may come to view themselves as worthless, incompetent, or unlovable. Family turmoil is an especially important source of frustration to adolescents. Occupational and interpersonal difficulties frequently precipitate suicide among adults.

5. The common emotion in suicide is hopelessness–helpless- ness. A pervasive sense of hopelessness, defined in terms of pessimistic expectations about the future, is even more im- portant than other forms of negative emotion, such as anger and depression, in predicting suicidal behavior. The suicidal person is convinced that absolutely nothing can be done to improve his or her situation; no one can help.

6. The common cognitive state in suicide is ambivalence. Most people who contemplate suicide, including those who eventually kill themselves, have ambivalent feelings about this decision. They are sincere in their desire to die, but they simultaneously wish that they could find another way out of their dilemma.

7. The common perceptual state in suicide is constriction. Suicidal thoughts and plans are frequently associated with a rigid and narrow pattern of cognitive activity that is analo- gous to tunnel vision. The suicidal person is temporarily unable or unwilling to engage in effective problem-solving behaviors and may see his or her options in extreme, all-or-nothing terms.

8. The common action in suicide is escape. Suicide provides a definitive way to escape from intolerable circumstances, which include painful self-awareness (Baumeister, 1990).

9. The common interpersonal act in suicide is communication of intention. One of the most harmful myths about suicide is the notion that people who really want to kill themselves don’t talk about it. Most people who commit suicide have told other people about their plans. Many have made previ- ous suicidal gestures.

10. The common pattern in suicide is consistency of lifelong styles. During crises that precipitate suicidal thoughts, peo- ple generally employ the same coping responses that they have used throughout their lives. For example, people who have refused to ask for help in the past are likely to persist in that pattern, increasing their sense of isolation.

138 CHAPTER 5 mood disorders and suicide

the immediate crisis and then refer him or her to mental health professionals.

Public and professional enthusiasm for suicide prevention cen- ters peaked during the 1960s and 1970s. Unfortunately, data that were reported in the 1970s and 1980s did not support optimis- tic claims that these centers were “saving lives.” Empirical studies showed that suicide rates do not differ in comparisons of similar communities that either have or do not have suicide prevention programs. Availability of crisis centers and hotlines does not seem to reduce suicide rates in communities (Brown et al., 2007; Lester, 2002).

Why don’t hotlines reduce suicide rates? The challenges faced by these programs are enormous. Think about the characteristics of people who are driven to contemplate suicide. They are often socially isolated, feeling hopeless, and unable to consider alterna- tive solutions. Many people with the most lethal suicidal ideation will not call a hotline or visit a drop-in crisis center. In fact, most clients of suicide prevention centers are young women; most sui- cides are committed by elderly men. The primary problem faced by suicide prevention programs is this: The people who they are trying to serve are, by definition, very difficult to reach.

It might be hard to justify the continued existence of crisis centers and hotlines if they are viewed solely in terms of suicide prevention. Only a small proportion of people who call hotlines are seriously suicidal. Most are people who are experiencing se- rious difficulties and who need to talk to someone about those problems. The value of contact with these individuals should not be underestimated. Crisis centers and hotlines provide support and assistance to very large numbers of people in distress. These services are undoubtedly valuable in their own right, even if seri- ous questions remain about their impact on suicide rates.

PSYChOThErAPY Psychological interventions with people who are suicidal can take many forms. These include all the standard approaches to psychotherapy. The research evidence indicates that cognitive behavior therapy does lead to a significant reduction in suicidal behavior, at least over short- and medium-term follow-up periods (Tarrier, Taylor, & Gooding, 2008). Psychological treat- ments can address underlying problems that set the stage for the person’s current problems. Additional treatment guidelines are also dictated by the threat of suicide. The following recommenda- tions cover special considerations that are particularly important when clients have expressed a serious intent to harm themselves (adapted from Berman & Jobes, 1994):

1. Reduce lethality. The most important task is to reduce the person’s experience of psychological pain from which the person is seeking escape. At a more concrete level, this also involves reducing access to means that could be used to com- mit suicide, such as guns and pills.

2. Negotiate agreements. Therapists frequently ask clients who have threatened to kill themselves to sign a contract, in which

(Stockard & O’Brien, 2002). For example, religious affiliation is significantly related to suicide rates. The active social networks en- couraged by some church communities can become an important source of emotional support during difficult times, protecting the person from the potential influence of self-destructive impulses.

Social policies regulating access to firearms, especially hand- guns, also have an effect on suicide rates. Guns are a particularly lethal method of suicide, accounting for more than 60 percent of the 35,000 to 40,000 deaths that occur in the United States each year (Hendin, 1995). In states and countries with restrictive gun laws, the suicide rate usually drops, particularly among adoles- cents (Brent & Bridge, 2003; Kapusta et al., 2007). Of course, people who have definitely decided to end their own lives inevi- tably find a way to accomplish that goal, but many people who attempt suicide are ambivalent in their intent. Many attempts are made impulsively. Ready access to guns increases the chance that a person who does engage in an impulsive suicide attempt will die, because gunshot wounds are very likely to be fatal.

Treatment of Suicidal People Efforts to avoid the tragic consequences of suicidal behavior can be organized at several levels. One approach would focus on social structures that affect an entire society. Durkheim’s theory of suicide, for example, indicates that the social structure of a society influences suicide rates. The social factors that we have just considered suggest some changes that could be made in con- temporary Western societies in an effort to reduce the frequency of suicide. For example, more restrictive gun control laws might minimize access to the most lethal method of self-destruction. More cautious reporting by the media of suicidal deaths might reduce the probability of cluster suicides. These are, of course, controversial decisions, in which many other considerations play an important role. The media, for example, are motivated to report stories in a way that will maximize their popularity with the public. And many people oppose gun control legislation for reasons that have nothing to do with suicide rates. Therefore, it may be unrealistic to hope that these measures, aimed broadly at the level of an entire population, would be implemented widely. Most treatment programs that are concerned with suicidal behavior have been directed toward individual persons and their families.

CriSiS CENTErS AND hOTLiNES Many communities have estab- lished crisis centers and telephone hotlines to provide support for people who are distraught and contemplating suicide. The purpose of these programs is typically viewed in terms of suicide preven- tion. Sponsored by various agencies, including community mental health centers, hospitals, and religious groups, these services are often staffed by nonprofessionals, frequently volunteers. They of- fer 24-hour-a-day access to people who have been trained to pro- vide verbal support for those who are in the midst of a crisis and who may have nowhere else to turn. Rather than provide ongoing treatment, most crisis centers and hotlines help the person through

mood disorders and suicide CHAPTER 5 139

fluvoxamine (Luvox) and fluoxetine (Prozac), because of the link between suicide and serotonin disregulation. Extensive clinical reports suggest that the use of SSRIs in treating de- pression actually lowers suicide rates (Gibbons et al., 2007). It should also be noted, however, that placebo-controlled out- come studies have not addressed this specific question. Fur- thermore, cases have been reported in which treatment with SSRIs has been followed by the development of new suicidal ideation (King, Segman, & Anderson, 1994). This pattern sug- gests that the relation between serotonin and suicide is neither direct nor simple and that caution is warranted in the use of SSRIs in treating suicidal clients (see Critical Thinking Matters on page 131).

iNvOLuNTArY hOSPiTALizATiON People who appear to be on the brink of committing suicide are often hospitalized, either with their permission or involuntarily (see Chapter 18 for a discussion of the legal issues involved in this process). The primary consideration in such cases is safety. In many cases, commitment to a hospital may be the best way to prevent people from harming themselves. The person’s behavior can be monitored continuously, access to methods of harming oneself can be minimized (although perhaps not entirely eliminated), and various types of treatment can be provided by the hospital’s professional staff.

the client agrees to postpone self-destructive behavior for at least a short period of time. Of course, these agreements can be broken, but they may provide brakes to inhibit impulsive actions.

3. Provide support. It is often useful to make concrete arrange- ments for social support during a suicidal crisis. Friends and family members are alerted and asked to be available so that the person is not alone.

4. Replace tunnel vision with a broader perspective. People who are seriously contemplating suicide are typically unable to consider alternative solutions to their problems. The thera- pist must help potential suicide victims develop or recover a more flexible and adaptive pattern of problem solving.

MEDiCATiON Treatment of mental disorders, especially depres- sion, anxiety, and schizophrenia, is usually the most important element of intervention with suicidal clients. The use of various types of medication is often an important part of these treatment efforts. Antidepressant drugs are frequently given to patients who are clinically depressed, and antipsychotic medication is useful with those who meet the diagnostic criteria for schizophrenia (see Chapter 13).

Considerable attention has been devoted recently to the use of selective serotonin reuptake inhibitors (SSRIs), such as

getting hElP

The distinction between severe depression and the ups and downs of everyday life provides an important guide to the need for treatment. If you have been seriously depressed for several weeks and if depression is interfering with your ability to function, you should seek professional help. For- tunately, you have already taken the first step toward improve- ment. By reading this chapter, you can learn to recognize the symptoms of mood disorders.

Several effective forms of treatment are available for mood disorders. The first step in getting help is to find someone with whom you can talk. This might be your family physician, some- one at your school’s counseling center, or a therapist in private practice. It is important that you feel comfortable with the per- son you choose and with the form of treatment that she or he will provide.

Depression is not uncommon, but people who are depressed of- ten feel lonely and alienated. A number of good books may help make it easier for you to find the right treatment for yourself. Various forms of treatment, including antidepressant medication, are described in Understanding Depression: What We Know and What You Can Do About It, by Raymond DePaulo. Self-help

books may be useful to people whose depression has not reached severe proportions. The cognitive approach to therapy is described with exceptional clarity in Feeling Good: The New Mood Therapy, by David Burns. Helpful information regarding bipolar disorder can be found in The Bipolar Disorder Survival Guide, by David Miklowitz.

People who are depressed need support and encouragement to seek treatment. Families and friends of depressed people find themselves in a very difficult and challenging situation. Mood disorders interfere with the person’s ability to get along with other people and deplete his or her energy and motivation for seeking treatment. If the person doesn’t follow through with therapy or make noticeable improvements after several sessions, friends can easily become discouraged or frustrated. Don’t feel guilty if your efforts appear to go unrewarded. And don’t blame the depressed person if he or she doesn’t get better right away. Mood disorders are serious problems that require professional help. More detailed advice for families and friends can be found in a useful book entitled How You Can Survive When They’re Depressed: Living and Coping with Depression Fallout, by Anne Sheffield.

140 CHAPTER 5 mood disorders and suicide

Mood disorders are defined in terms of emotional, cognitive, behavioral, and somatic symptoms. In addition to a feeling of pervasive despair or gloom, people experiencing an episode of major depression are likely to show a variety of symptoms, such as diminished interest in normal activities, changes in appetite and sleep, fatigue, and problems in concentration.

A person in a manic episode feels elated and energetic. Manic patients also exhibit related symptoms, such as inflated self-esteem, rapid speech, and poor judgment.

DSM-5 lists two major categories of mood disorders. People with depressive disorders experience only episodes of depres- sion. People with bipolar disorders experience episodes of mania, which are most often interspersed with episodes of depression. There are several specific types of depressive disorders in DSM-5. Major depressive disorder is diagnosed if the person has experienced at least one episode of major depression without any periods of mania. Persistent depressive disorder (dysthymia) is a less severe, chronic form of depres- sion in which the person has been depressed for at least two years without a major depressive episode.

A person who has experienced at least one manic episode would receive a diagnosis of bipolar I disorder, regardless of whether he or she has ever had an episode of depression. One episode of major depression combined with evidence of at least one period of hypomania would qualify for a diagnosis of bipolar II disorder. Cyclothymia is a less severe, chronic form of bipolar disorder in which the person has experienced numerous periods of hypomania interspersed with periods of depressed mood.

Mood disorders are among the most common forms of psycho- pathology. Epidemiological studies have found that the lifetime risk for major depressive disorder is approximately 16 percent and the lifetime risk for persistent depressive disorder is approx- imately 3 percent. Rates for both of these disorders are two or three times higher among women than among men. The lifetime risk for bipolar I and II disorders combined is close to 4 percent.

The causes of mood disorders can be traced to the combined effects of social, psychological, and biological factors. Social factors include primarily the influence of stressful life events,

especially severe losses that are associated with significant peo- ple or significant roles.

Cognitive theories are primarily concerned with the way in which depressed people experience a severe event.

Interpersonal theories focus on the ways in which individuals respond to people and events in their environments. Depressed people behave in ways that have a negative impact on other people. In this way they contribute to the stressful nature of their social environment.

Twin studies indicate that genetic factors play an important role in the etiology of both depressive and bipolar disorders. They also indicate that genetic factors may play a stronger role in the development of bipolar than depressive disorders. Genes may contribute to the development of depression directly through an effect on the central nervous system and indirectly by influ- encing the person’s sensitivity to environmental events, such as severe stress.

Neurochemical messengers in the brain also play a role in the regulation of mood and the development of mood disorders. Current thinking is focused on serotonin, norepinephrine, and dopamine, although many other neurotransmitter substances may also be involved in depression.

Several types of psychological and biological treatments have been shown to be effective for mood disorders. Two types of psychotherapy, cognitive therapy and interpersonal therapy, are beneficial for depressive and dysthymic patients. Three types of antidepressant medications are also useful in the treatment of major depressive disorder: selective serotonin reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors. Medication and psychotherapy are frequently used together. Outcome studies do not consistently favor either psychological or psychopharmacologic treatment.

Three other types of biological treatments are beneficial for specific types of mood disorders. Lithium carbonate and cer- tain anticonvulsant drugs are useful for patients with bipolar disorders. Electroconvulsive therapy has been shown to be effective in the treatment of certain depressed patients, and it may be especially useful for patients who are severely suicidal or have failed to respond to other types of treatments. Light therapy seems to be effective for managing seasonal affective disorders.

People commit suicide for many different reasons. Most people who kill themselves are suffering from some form of mental dis- order, such as depression, substance abuse, or schizophrenia. For some people, suicide represents an escape from unbearable negative emotions, which are often associated with social isola- tion and the perception of being a burden to others.

Summary5

mood disorders and suicide CHAPTER 5 141

5.1 What is the difference between clinical depression and a low mood? There is not an obvious marker to identify when sadness crosses over to serious depression, but several considerations help clinicians identify the disorder. These include duration of the depressed mood, presence of associated symptoms, and an inability to occasionally en- joy activities that would otherwise provide some relief from feeling down or blue . . . (see page 108).

5.2 Are there different kinds of depression? The easy (and short) answer is “yes.” Many systems have been pro- posed to identify meaningful subtypes of depressive disorders. In addition to recognizing differences between major depression and persistent depressive disorder, DSM-5 uses episode specifiers and course specifiers to describe this heterogeneous set of problems . . . (see page 115).

5.3 How do depressive and bipolar disorders differ? The age of onset and course of these disorders vary from one person to the next, but—on average—bipolar disorders have an earlier age of onset and bipolar patients typically experience more episodes over their lifetime . . . (see pages 116–117).

5.4 Are we more likely to experience depression as we get older? Although many people mistakenly identify depression with the el- derly, epidemiological studies have shown that mood disorders actu- ally are most frequent among young and middle-aged adults . . . (see page 118).

5.5 Why do some people become depressed after stressful life events while others do not? Part of the answer depends on how a person interprets the event. Does he or she exaggerate the importance of the negative event, blowing it out of proportion? . . . (see page 121).

5.6 Is psychological treatment as effective as medication in treating depression? The bottom line is that medication and psychotherapy are approximately equivalent in the treatment of people who are chroni- cally depressed . . . (see page 130).

5.7 Why do some people want to end their own lives? The desire to die is linked closely to social isolation and the belief that one has become a burden to others . . . (see page 137).

critical thinking review

The Big Picture

key terms affect 106 analogue studies 127 bipolar disorders 107 clinical depression 107 cyclothymia 115 depressed mood 106 depressive disorders 107

dysphoric 109 euphoria 107 hypomania 114 mania 107 melancholia 115 monoamine oxidase inhibitors

(MAOis) 129

mood 106 mood disorders 107 persistent depressive

disorder (dysthymia) 112 psychomotor retardation 111 relapse 116 remission 116

seasonal affective disorder 116

selective serotonin reuptake inhibitors (SSris) 128

somatic symptoms 110 tricyclics antidepressants

(TCAs) 129

142 CHAPTER 5 mood disorders and suicide

Virtual Case Studies

Virtual Case Studies offers you a science-based, interactive simulation where you can learn how a number of risk factors and protective factors could impact disorder development in a virtual person. As you progress through the simulation you will not act as the character or as a clinician, but will be able to independently explore a variety of different behaviors, events, and outcomes that one who suffers from a disorder could potentially encounter. You can access the Virtual Case Study on Mood Disorders at mypsychlab.com

FPO

6

anxiety disorders and obsessive-compulsive disorder

144 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

6 The Big Picture learning objectives

6.1 Why is a panic attack sometimes calleda “false alarm?”

6.2 What is the expected long-term outcome for people with

anxiety disorders?

6.3 Is there a unique causal pathway for each type of anxiety

disorder?

6.4 If phobias are learned quickly and easily, why are they so

hard to extinguish?

6.5 Do psychological treatments have any advantages

over medication for treatment of anxiety?

6.6 What is the difference between obsessions and normal

intrusive thoughts?

6.7 Why is response prevention coupled with exposure in the

treatment of OCD?

Fear and anxiety play important roles in all of our lives. Fear helps us avoid danger in our immediate environment. Have you ever jumped out of the street to avoid a car that was unexpectedly rush- ing toward you? Or run away from an animal with a menacing growl? The sudden burst of fear that you experienced allowed you to react immediately. Anxiety is focused on the future rather than the immediate present. It helps us anticipate and prepare for impor- tant events. Remember when you called someone for the first time, performed at a musical recital, or spoke up in class? If you felt anx- ious in the time leading up to this event, you may have also noticed that your heart was pounding, your mouth was dry, and you were breathing faster. These are some of the physical signs of anxiety. Anxiety may be unpleasant, but it is often adaptive; we would have trouble organizing our lives if it were eliminated completely. Un- fortunately, anxiety can also disrupt our lives. There are many ways in which anxiety can become maladaptive. It is often a question of degree rather than kind. We can worry too much, feel anxious too often, or be afraid at inappropriate times. In this chapter we will

explore many of the important distinctions that psychologists make among phenomena such as fear, anxiety, worry, and panic. We will discuss the ways in which these experiences can become maladap- tive and the ways in which the problems can be treated.

A related set of disorders involves various forms of persistent, intrusive thoughts and troublesome habitual behaviors. We will discuss obsessive-compulsive disorder (OCD) and some of its re- lated disorders, such as trichotillomania (hair-pulling disorder), in the latter half of this chapter. OCD was formerly grouped to- gether with anxiety disorders, but it has been moved to its own chapter and separated from the anxiety disorders in DSM-5.

Overview Taken together, the various forms of anxiety disorders—including phobias, panic attacks, social anxiety, and extreme worry—repre- sent the most common type of abnormal behavior. The National Comorbidity Survey Replication (NCS-R) found that 18 percent of adults in the U.S. population have at least one type of anxiety disorder in any given year (Kessler et al., 2009). This figure was higher than the one-year prevalence rates that were observed for mood disorders (10 percent) and substance use disorders (4 per- cent). Anxiety disorders lead to significant social and occupational impairment and a reduced quality of life (Tolin et al., 2010).

Anxiety disorders share several important similarities with mood disorders. From a descriptive point of view, both catego- ries are defined in terms of negative emotional responses. Feelings such as guilt, worry, and anger frequently accompany anxiety and depression. Many patients who are anxious are also depressed, and, similarly, many patients who are depressed are also anxious (Kessler et al., 2008; Shankman & Klein, 2003). The order in which these problems emerge in the person’s life can vary, but usually anxiety precedes the onset of depression.

The close relationship between symptoms of anxiety and those for depression suggests that these disorders may share com- mon causal features. In fact, stressful life events seem to play a role in the onset of both depression and anxiety. Cognitive factors are also important in both types of problems. From a biological point of view, certain brain regions and a number of neurotrans- mitters are involved in the etiology of anxiety disorders as well as mood disorders (Ressler & Mayberg, 2007).

The following case study illustrates the kinds of symptoms that are included under the heading of anxiety disorders. You should no- tice the overlap among different features of anxiety disorders, including panic, worry, avoidance, and a variety of alarming physical sensations. This narrative was written by Johanna Schneller (1988), a freelance writer who has been treated for panic disorder. Agoraphobia refers to an exaggerated fear of being in situations from which escape might be dif- ficult, such as being caught in a traffic jam on a bridge or in a tunnel.

A Writer’s Panic Disorder with Agoraphobia Three years have passed since my first panic attack struck, but even now I can close my eyes and see the small supermarket

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 145

I felt responsible for ruining other people’s good time. One attack occurred while I was in a tiny boat deep sea fishing with my fam- ily; another hit when I was on a weekend canoe trip with my boy- friend. I also suffered a terrifying attack while on my way to see friends, stuck in traffic, merging into a tunnel near Boston’s Logan Airport, with no exit ramp or emergency lane in sight.

“I began declining offers I wanted to accept: All I could think was, ‘What if I panic in the middle of nowhere?’ The times I did force myself to go out, I sat near the doors of restaurants, in aisle seats at movie theaters, near the bathroom at parties. For some reason, I always felt safe in bathrooms, as if whatever happened to me there would at least be easy to clean up.

“On days when I didn’t have an actual attack, I could feel one looming like a shadow over my shoulder; this impending panic was almost worse than the real thing. By remembering old episodes, I brought on new ones, and each seemed to pull me closer to a vi- sion I had of my mind snapping cleanly in half, like a stalk of celery.”

Johanna’s description of her problems raises a number of interest- ing questions, to which we will return later in the chapter. Was it just a coincidence that her first attack occurred shortly after the difficult experience of moving to a new city, starting a new job, and finding a new apartment? Could the stress of those experi- ences have contributed to the onset of her disorder? Was there a pattern to her attacks? Why did she feel safe in some situations and not in others? She mentions feeling out of control, as if she were responsible for her attacks. Could she really bring on an- other attack by remembering one from the past?

Symptoms of Anxiety Disorders People with anxiety disorders share a preoccupation with, or per- sistent avoidance of, thoughts or situations that provoke fear or anxiety. Anxiety disorders frequently have a negative impact on various aspects of a person’s life. Johanna found that anxiety and its associated problems constrained both her ability to work and her social relationships. Most people who knew Johanna probably did not know that she suffered from a mental disorder. In spite of the private terrors that she endured, she was able to carry on most aspects of her life.

In addition to these general considerations, the diagnosis of anxiety disorders depends on several specific types of symptoms, which we discuss in the following sections. We begin with the na- ture of anxiety, which should be distinguished from more discrete emotional responses, like fear and panic.

Anxiety Like depression, the term anxiety can refer to either a mood or a syndrome. Here, we use the term to refer to a mood. Specific syndromes associated with anxiety disorders are discussed later in the chapter.

where it happened. I can feel the shoppers in their heavy coats jostling me with their plastic baskets, and once again my stomach starts to drop away.

“It was November. I had just moved to New York City and completed a long search for a job and an apartment. The air felt close in that checkout line, and black fuzz crept into the corners of my vision. Afraid of fainting, I began to count the number of shoppers ahead of me, then the number of purchases they had. The overhead lights seemed to grow brighter. The cash register made pinging sounds that hurt my ears. Even the edges of the checkout counter looked cold and sharp. Suddenly I became nau- seated, dizzy. My vertigo intensified, separating me from every- one else in the store, as if I were looking up from underwater. And then I got hot, the kind of hot you feel when the blood seems to rush to your cheeks and drain from your head at the same time.

“My heart was really pounding now, and I felt short of breath, as if wheels were rolling across my chest. I was terrified of what was happening to me. Would I be able to get home? I tried to talk my- self down, to convince myself that if I could just stay in line and act as if nothing was happening, these symptoms would go away. Then I decided I wasn’t going to faint—I was going to start screaming. The distance to the door looked vast and the seconds were crawl- ing by, but somehow I managed to stay in the checkout line, pay for my bag of groceries, and get outside, where I sat on a bench, gulp- ing air. The whole episode had taken ten minutes. I was exhausted.

“At home, I tried to analyze what had happened to me. The experience had been terrifying, but because I felt safe in my kitchen, I tried to laugh the whole thing off—really, it seemed ri- diculous, freaking out in a supermarket. I decided it was an isolated incident; I was all right, and I was going to forget it ever happened.

“Two weeks later, as I sat in a movie theater, the uncomfort- able buzz began to envelop me again. But the symptoms set in faster this time. I mumbled something to my friends about feeling sick as I clambered over them. It was minutes before I caught my breath, hours before I calmed down completely.

“A month full of scattered attacks passed before they started rolling in like Sunday evenings, at least once a week. I tried to find a pattern: They always hit in crowded places, places difficult to escape. My whole body felt threatened, primed to run during an attack. Ironically, my attacks were invisible to anyone near me unless they knew what to look for—clenched neck muscles, rest- less eyes, a shifting from foot to foot—and I was afraid to talk to anyone about them, to perhaps hear something I wouldn’t want to hear. What if I had a brain tumor? And I was embarrassed, as if it were my fault that I felt out of control. But then one night I had an attack alone in my bed—the only place I had felt safe. I gave in and called a doctor.

“As the weeks passed and the attacks wore on, I began to think maybe I was crazy. I was having attacks in public so often I became afraid to leave my house. I had one on the subway while traveling to work almost every morning but, luckily, never pan- icked on the job. Instead, I usually lost control in situations where I most wanted to relax: on weekend trips, or while visiting friends.

146 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

of diffuse negative emotion, (2) a sense of uncontrollability, and (3) a shift in attention to a primary self-focus or a state of self-preoccupation (Barlow, 2004).

Excessive Worry Worrying is a cognitive activity that is associated with anxiety. In recent years psychologists have studied this phenomenon care- fully because they consider it to be critical in the subclassification of anxiety disorders (DSM-5). Worry can be defined as a rela- tively uncontrollable sequence of negative, emotional thoughts that are concerned with possible future threats or danger. This sequence of worrisome thoughts is usually self-initiated or pro- voked by a specific experience or ongoing difficulties in the per- son’s daily life. When excessive worriers are asked to describe their thoughts, they emphasize the predominance of verbal, linguistic material rather than images (Borkovec, Alcaine, & Behar, 2004). In other words, worriers are preoccupied with “self-talk” rather than unpleasant visual images.

Because everyone worries at least a little, you might won- der whether it is possible to distinguish between pathological and normal worry. The answer is yes, but there is not a clear line that divides the two kinds of experiences. The distinction hinges on quantity—how often the person worries and about how many different topics the person worries. It also depends on the quality of worrisome thought. Excessive worriers are more likely than other people to report that the content of their thoughts is negative, that they have less control over the content and direction of their thoughts, and that in compari- son to other adults, their worries are less realistic (Newman & Llera, 2010).

Anxious mood is often defined in contrast to the specific emotion of fear, which is more easily understood. Fear is expe- rienced in the face of real, immediate danger. It usually builds quickly in intensity and helps organize the person’s behavioral responses to threats from the environment (escaping or fight- ing back). Classic studies of fear among normal adults have often focused on people in combat situations, such as airplane crews during bombing missions over Germany in World War II (Rachman, 1991). In contrast to fear, anxiety involves a more general or diffuse emotional reaction—beyond simple fear—that is out of proportion to threats from the environment (Barlow, 2004). Rather than being directed toward the person’s present circumstances, anxiety is associated with the anticipation of fu- ture problems.

Anxiety can be adaptive at low levels, because it serves as a signal that the person must prepare for an upcoming event. When you think about final exams, for example, you may be- come somewhat anxious. That emotional response may help to initiate and sustain your efforts to study. In contrast, high lev- els of anxiety become incapacitating by disrupting concentration and performance.

A pervasively anxious mood is often associated with pes- simistic thoughts and feelings (“If something bad happens, I probably won’t be able to control it”). The person’s attention turns inward, focusing on negative emotions and  self- evaluation (“Now I’m so upset that I’ll never be able to con- centrate during the exam!”) rather than on the organization or rehearsal of adaptive responses that might be useful in coping with negative events. Taken together, these factors can be used to define anxious apprehension, which consists of (1) high levels

Fear is a response to immediate danger, while anxi- ety is concerned with events that might happen in the future.

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 147

impending heart attack or racing thoughts as evidence that they are about to lose their minds.

Panic attacks are further described in terms of the situations in which they occur, as well as the person’s expectations about their occurrence. An attack is said to be expected, or cued, if it occurs only in the presence of a particular stimulus. For exam- ple, someone who is afraid of public speaking might have a cued panic attack if forced to give a speech in front of a large group of people. Unexpected panic attacks, like Johanna’s experience in the grocery checkout line, appear without warning or expectation, as if “out of the blue.”

Phobias In contrast to both diffuse anxiety, which represents a blend of negative emotions, and panic attacks, which are frequently unexpected, phobias are persistent, irrational, narrowly de- fined fears that are associated with a specific object or situa- tion. Avoidance is an important component of the definition of phobias. A fear is not considered phobic unless the person avoids contact with the source of the fear or experiences in- tense anxiety in the presence of the stimulus. Phobias are also irrational or unreasonable. Avoiding only snakes that are poi- sonous or only guns that are loaded would not be considered phobic.

The most straightforward type of phobia involves fear of specific objects or situations. Different types of specific pho- bias have traditionally been named according to the Greek words for these objects. Examples of typical specific phobias include fear of heights (acrophobia), fear of enclosed spaces (claustrophobia), fear of small animals (zoophobia), fear of blood (hemophobia), fear of flying on airplanes (aerophobia), and fear of being in places from which escape might be diffi- cult (agoraphobia).

Diagnosis of Anxiety Disorders The DSM-5 (APA, 2013) approach to classifying anxiety disor- ders is based primarily on descriptive features and recognizes sev- eral specific subtypes. They include specific phobia, social anxiety disorder (social phobia), panic disorder, agoraphobia, and gener- alized anxiety disorder. The manual also describes problems with anxiety that appear in children, specifically separation anxiety dis- order and selective mutism. These problems will be discussed in Chapter 16.

Some other conditions that are often associated with the experience of anxiety should also be mentioned. Obsessive- compulsive and related disorders are described in a separate chapter in DSM-5; they will be discussed in the second part of this chapter. Post-traumatic stress disorder (PTSD) and acute stress disorder are also closely associated with anxiety disorders. We will discuss PTSD and acute stress disorder in Chapter 7.

Panic Attacks A panic attack is a sudden, overwhelming experience of terror or fright, like the attack that was experienced by Johanna as she waited in the checkout line. Whereas anxiety involves a blend of several negative emotions, panic is more focused. Some clinicians think of panic as a normal fear response that is triggered at an in- appropriate time (Barlow, Brown, & Craske, 1994). In that sense, panic is a “false alarm.” Descriptively, panic can be distinguished from anxiety in two other respects: It is more intense, and it has a sudden onset.

Panic attacks are defined largely in terms of a list of somatic or physical sensations, ranging from heart palpi- tations, sweating, and trembling to nausea, dizziness, and chills. DSM5: Diagnostic Criteria for Panic Disorder lists the DSM-5 criteria for panic disorder, and the criteria for a panic attack appear at the beginning of that definition. A person must experience at least four of these 13 symptoms in order for the experience to qualify as a full-blown panic at- tack. The symptoms develop suddenly, and they usually reach a peak intensity within 10 minutes. The actual numbers and combinations of panic symptoms vary from one person to the next, and they may also change over time within the same person.

People undergoing a panic attack also report a number of cognitive symptoms. They may feel as though they are about to die, lose control, or go crazy. Some clinicians believe that the mis- interpretation of bodily sensations lies at the core of panic disor- der. Patients may interpret heart palpitations as evidence of an

MyPsychLab VIDEO CASE

Generalized Anxiety Disorder

PHILIP

“I worry a lot, I just analyze, analyze, until I’m paralyzed.”

Watch the Video Philip: Generalized Anxiety Disorder on MyPsychLab

CHRISTY

“It’s impacted a lot of my close relation- ships, or potential to bond with others.”

Watch the Video Christy: Generalized Anxiety Disorder with Insomnia on MyPsychLab

Watch both interviews and ask yourself what symptoms these two people have in common. Then ask yourself how they are different. People with GAD share some important similarities, but they are not identical.

148 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

People with social anxiety disorder are afraid of (and avoid) social situations in which they may be scrutinized. These situations fall into two broad headings: doing something in front of unfamil- iar people (performance anxiety) and interpersonal interactions (such as dating and parties). Fear of being humiliated or embar- rassed presumably lies at the heart of the person’s discomfort. Some people have a circumscribed form of social anxiety that is focused on one particular type of situation. Examples include giving a speech, playing a musical instrument, urinating in a public rest room, or eating in a restaurant. For these people, the feared task could be completed easily if they were able to do it privately. In other cases, the fear is more generalized, and the person is intensely anxious in almost any situation that involves social interaction. This type of person might be described as being extremely shy.

AGORAPHOBIA The least circumscribed form of phobia is agoraphobia, which literally means “fear of the marketplace (or places of assembly)” and is usually described as fear of public spaces. It is often associated with a pervasive avoidance of many

SPECIFIC PHOBIA A specific phobia is defined in DSM-5 as “a marked fear or anxiety about a specific object or situation that almost always provokes immediate fear or anxiety” (APA, 2013, p. 197). This object or situation is actively avoided (or endured with intense fear or anxiety) and the fear or anxiety is out of proportion to the actual danger posed by the object or situa- tion. Frequently observed types of specific phobias include fear of heights, small animals (such as spiders, bugs, mice, snakes, or bats), and being in a closed place (such as a very small room). Exposure to the phobic stimulus must be followed by an im- mediate fear response. DSM-5 also provides a severity threshold: The avoidance or distress associated with the phobia must inter- fere significantly with the person’s normal activities or relation- ships with others, and it must be persistent (typically lasting six months or more).

SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA) The DSM-5 definition of social anxiety disorder is almost identical to that for specific phobia, but it is focused on social situations in which the person may closely observed or evaluated by other people.

DSM-5criteria forPanic Disorder

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

Note: The abrupt surge can occur from a calm state or an anx- ious state.

1. Palpitations, pounding heart, or accelerated heart rate. 2. Sweating. 3. Trembling or shaking. 4. Sensations of shortness of breath or smothering. 5. Feelings of choking. 6. Chest pain or discomfort. 7. Nausea or abdominal distress. 8. Feeling dizzy, unsteady, light-headed, or faint. 9. Chills or heat sensations.

10. Paresthesias (numbness or tingling sensations). 11. Derealization (feelings of unreality) or depersonalization

(being detached from oneself). 12. Fear of losing control or “going crazy.” 13. Fear of dying.

Note: Culture-specific symptoms (e.g., tinnitus, neck sore- ness, headache, uncontrollable screaming or crying) may be

seen. Such symptoms should not count as one of the four required symptoms.

B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1. Persistent concern or worry about additional panic attacks

or their consequences (e.g. losing control, having a heart attack, “going crazy”).

2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).

C. The disturbance is not attributable to the physiological ef- fects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopul- monary disorders).

D. The disturbance is not better explained by another mental dis- order (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 149

THINKING CRITICALLY about DSM-5

Splitting Up the Anxiety Disorders

Experts who classify mental disorders can be described informally as belonging to one of two groups: “lumpers” and “splitters” (Rousseau, 2009; Wittchen, Schuster, & Lieb, 2001). Lumpers would argue that anxiety is a generalized condition or set of symptoms without any special subdivisions. Splitters would distinguish among a number of more specific con- ditions, each of which is presumed to have its own unique causes and perhaps respond best to a particular form of treatment. The popularity of these approaches tends to swing back and forth over the years. Throughout most of the twentieth century, psychiatrists tended to adopt a generalized position with regard to anxiety disorders (see Jablensky, 1985). In other words, they lumped together all kinds of problems under a very broad title of anxiety disorders.

Beginning with DSM-III (APA, 1980), the pendulum swung back in the opposite direction (toward splitting and away from lump- ing). That approach—dividing the anxiety disorders into smaller, distinct types—has become increasingly popular over the past 30 years. Now DSM-5 has taken splitting to a new level. Two dis- orders that were previously listed as types of anxiety disorders– OCD and PTSD–have been removed from the group of anxiety disorders to create their own chapters (or headings), with other descriptively similar conditions being organized under these new umbrella terms. The rationale for this fairly dramatic change is grounded in the desire to group together conditions that are descriptively most similar. For example, the problems listed under “Obsessive-Compulsive and Related Disorders” share prominent features that involve intrusive thoughts and habitual behaviors. Problems listed under “Trauma- and Stress-Related Disorders” all involve exposure to a traumatic or stressful event as one required criterion for their diagnosis. The net effect of these changes is that the problems formerly known as anxiety disorders now cover three separate chapters in DSM-5.

The impact of this shift in the classification of anxiety disorders is clearly increased precision. The essential features and diag- nostic boundaries of these conditions have been clarified. In that sense, the change is helpful and not particularly controversial. On the other hand, you should not be misled into thinking that the new organizational structure for these disorders reflects a major shift in our understanding of the causes of these disorders

or a dramatic improvement in the efficacy of treatment methods aimed at specific types of disorder. It does not. The text in DSM- 5 says that the separate chapters were created to “reflect the in- creasing evidence of these disorders’ relatedness to one another in terms of a range of diagnostic validators as well as the clinical utility of grouping these disorders in the same chapter.” That’s psychobabble for “we think they look alike.”

At the same time that OCD and PTSD are being listed sepa- rately from other disorders that involve high levels of anxiety, the field has also begun to embrace a more integrated and uni- fied perspective with regard to anxiety disorders and mood dis- orders (Brown & Barlow, 2009; Kendler et al., 2011; Krueger & Markon, 2006). In other words, there is also a swing back in the direction of lumping, and it is reflected in the organizational sequence of chapters in DSM-5 (i.e., bipolar disorders, depres- sive disorders, anxiety disorders, obsessive-compulsive related disorders, trauma-related disorders, and dissociative disorders in that order). This part of the discussion regarding classification is focused on using a conceptual scheme that organizes various forms of psychopathology using two broad dimensions or spec- tra: internalizing and externalizing disorders. Mood disorders, anxiety, OCD-related disorders, and trauma-related disorders fall into the internalizing domain because they are all character- ized by symptoms that involve high levels of negative emotion and internal distress. Externalizing disorders (such as antisocial personality disorder and substance use disorders) are more con- cerned with failure to inhibit problematic behaviors (Andrews et al., 2009). In some ways, DSM-5 demonstrates the influence of both lumping and splitting.

Arguments about the relative merits of lumping and splitting in the classification of mental disorders are fundamentally ques- tions about the validity of diagnostic categories (see Chapter 4). Decisions regarding the breadth or specificity of anxiety disor- ders and various related conditions will ultimately depend on ev- idence from many areas. Do phobias and obsessive-compulsive disorder show distinct, separate patterns in family studies? Do they respond to different types of treatment? Can we distinguish between them in terms of typical patterns of onset and course? Definitive answers are not yet available. Future research efforts are needed to address these issues.

different kinds of situations, rather than one specific feared ob- ject or situation (as in other phobias). The case of Johanna at the beginning of this chapter provides a brief description of the types of problems experienced by a person suffering from agorapho- bia. Typical situations that are feared include crowded streets and shops, enclosed places like theaters and churches, traveling on

public transportation, and driving an automobile on bridges, in tunnels, or on crowded expressways. In any of these situations, the presence of a trusted friend may help the person with agora- phobia feel more comfortable. In the most extreme form of the disorder, agoraphobic patients are unable to venture away from their own homes.

150 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

DSM-5 defines agoraphobia in terms of anxiety about being in situations from which escape might be either difficult or em- barrassing. Avoidance and distress are important elements of the definition. In order to meet the DSM-5 criteria, the person must either avoid agoraphobic situations, such as traveling away from his or her own home; endure the experience with great distress; or insist on being accompanied by another person who can pro- vide some comfort or security. In most cases, the person avoids a wide variety of situations rather than just one specific type of situation.

PANIC DISORDER To meet the diagnostic criteria for panic dis- order, a person must experience recurrent, unexpected panic at- tacks (see DSM5: Diagnostic Criteria for Panic Disorder). At least one of the attacks must have been followed by a period of one month or more in which the person has either persistent con- cern about having additional attacks, or a significant maladaptive change in behavior related to the attacks (such as avoidance of exercise or unfamiliar situations).

GENERALIZED ANXIETY DISORDER Excessive anxiety and worry are the primary symptoms of generalized anxiety dis- order (GAD). The person must have trouble controlling these worries, and the worries must lead to significant distress or im- pairment in occupational or social functioning. The worry must occur more days than not for a period of at least six months, and it must be about a number of different events or activities. In order to distinguish GAD from other forms of anxiety disorder, DSM-5 notes that the person’s worries should not be focused on having a panic attack (as in panic disorder), being embarrassed in public (as in social anxiety disorder), or being contaminated (as in obsessive-compulsive disorder). Finally, the person’s worries and free-floating anxiety must be accompanied by at least three of the following symptoms: (1) restlessness or feeling keyed up or on edge, (2) being easily fatigued, (3) difficulty concentrat- ing or mind going blank, (4) irritability, (5) muscle tension, and (6) sleep disturbance.

Course and Outcome Anxiety disorders are often chronic conditions. Long-term follow-up studies focused on clinical populations indicate that many people continue to experience symptoms of anxiety and associated social and occupational impairment many years af- ter their problems are initially recognized. On the other hand, some people do recover completely. The most general conclusion, therefore, is that the long-term outcome for anxiety disorders is mixed and somewhat unpredictable (Ramsawh et al., 2009).

Most people with these disorders continue to have significant problems for many years (Beesdo-Baum et al., 2012; Rubio & Lopez-Ibor, 2007). The frequency and intensity of panic attacks tend to decrease as people reach middle age, but agoraphobic avoidance typically remains stable. The nature of the most promi- nent symptoms may also evolve over time. In patients with GAD,

MyPsychLab VIDEO CASE

Social Anxiety Disorder

STEVE

“I imagine that people are watching me. They are watching me stumble in my ef- forts. . . .”

Watch the Video Steve: Social Anxiety

Disorder (Social Phobia) on MyPsychLab

What is his worst fear when he is talking to another person at a party?

Specific phobias are irrational fears associated with specific situations that the person avoids. Acrophobia is the name given to fear of heights (which this climber clearly does not have).

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 151

syndromes? Or should we think about the existence of three types of disorders: “pure” anxiety disorders, “pure” mood disorders, and a third type of disorder that represents a mixture of anxiety and depression? Reasonable arguments have been made on both sides of this debate, which remains unresolved (Batelaan et al., 2012; Das-Munshi et al., 2008).

Substance dependence is another problem that is frequently associated with anxiety disorders. People who have an anxiety dis- order are about three times more likely to have an alcohol use disorder than are people without an anxiety disorder (Grant et al., 2004). In situations such as these, questions of cause and effect are not clear. Did the person use alcohol in an attempt to reduce heightened anxiety, or did he or she become anxious after drink- ing excessively? Prospective studies conclude that it works both ways (Kushner, Sher, & Erickson, 1999).

Gender Differences There are significant gender differences in lifetime prevalence for several types of anxiety disorders. Furthermore, among people who suffer from an anxiety disorder, relapse rates are higher for women than for men. The gender difference in prevalence is particularly large for specific phobias, where women are three times as likely as men to experience the disorder. Women are about twice as likely as men to experience panic disorder, agoraphobia (without panic disorder), and generalized anxiety disorder. Social anxiety disorder is also more common among women than among men, but the difference is not as striking as it is for other types of phobias.

The significant gender differences in the prevalence and course of anxiety disorders must be interpreted in the light of causal theories, which are considered in the next section. Several explanations remain plausible. Psychological speculation has fo- cused on such factors as gender differences in child-rearing prac- tices or differences in the way in which men and women respond to stressful life events. Gender differences in hormone functions or neurotransmitter activities in the brain may also be responsible (Altemus, 2006).

Anxiety Disorders Across the Life Span Prevalence rates for anxiety disorders have been found to be lower when people over the age of 60 are compared to younger adults (Kessler et al., 2005). On the other hand, the gradual reduction in anxiety that has been observed among middle-aged adults may reverse itself later in life. Anxiety may increase as people move into their 70s and 80s (O’Connor, 2006; Teachman, 2006). Increased anxiety among the elderly may be due to problems associated with loneliness, increased dependency, declining physical and cognitive capacities, and changes in social and economic conditions.

Most elderly people with an anxiety disorder have had the symptoms for many years. It is relatively unusual for a person to develop a new case of panic disorder, specific phobia, or social anxiety at an advanced age. The only type of anxiety disorder that begins with any noticeable frequency in late life is agoraphobia (Barlow et al., 2003).

worries may be replaced by complaints about physical symptoms. Worse outcomes tend to be associated with a younger age of on- set and lack of appropriate treatment.

Frequency of Anxiety Disorders Some epidemiological studies focus exclusively on treated cases of a disorder, but that strategy can provide a distorted view of the distribution of the disorder within the general population. Many factors can influence whether a person decides to seek treatment. Some cases are less severe than others. Some people treat them- selves without consulting a mental health professional. Some people are suspicious of medical facilities, and others are con- cerned about what people will think of them if they are treated for a mental disorder. Of course, people with agoraphobia are extremely reluctant to leave their homes for any reason. This is- sue has been a special problem in epidemiological studies of anxi- ety disorders. Only about 25 percent of people who qualify for a diagnosis of anxiety disorder ever seek psychological treatment. Therefore, our estimates of the frequency and severity of these problems must be based on community surveys.

Prevalence The National Comorbidity Survey Replication (NCS-R), which included approximately 9,000 people aged 18 and older through- out the United States, found that anxiety disorders are more com- mon than any other form of mental disorder (Kessler et al., 2005). Specific phobias are the most common type of anxiety disorder, with a one-year prevalence of about 9 percent of the adult popula- tion (men and women combined). Social anxiety disorder is almost as common, with a one-year prevalence of 7 percent. Panic disorder and GAD both affect approximately 3 percent of the population. Another 1 percent of the population meets criteria for agoraphobia.

Comorbidity The symptoms of various anxiety disorders overlap considerably. For example, many people who experience panic attacks develop phobic avoidance. More than 50 percent of people who meet the criteria for one anxiety disorder also met the criteria for at least one other form of anxiety disorder or mood disorder (Klein et al., 2012).

Both anxiety and depression are based on emotional distress, so it is not surprising that considerable overlap also exists between anxiety disorders and mood disorders (Kessler et al., 2008). Ap- proximately 60 percent of people who receive a primary diagnosis of major depression also qualify for a secondary diagnosis of some type of anxiety disorder. The average of age of onset for anxiety disorders is much younger than the average age of onset for de- pression, so when they are both present in the same person’s life, the usual pattern is for anxiety to appear first (Kessler et al., 2007).

This extensive overlap between anxiety and depression raises interesting questions about the relation between these general diagnostic categories. Do people who meet the criteria for both depression and an anxiety disorder really suffer from two distinct

152 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

2003). Cultural anthropologists have recognized many differ- ent cultural concepts of distress that, in some cases, bear striking resemblance to anxiety disorders listed in DSM-5.

Very few epidemiological studies have attempted to collect cross-cultural data using standardized interviews and specific diagnostic criteria. One such study was conducted to evaluate specific drugs for the treatment of panic attacks (Cross-National Collaborative Panic Study, 1992). More than 1,000 patients were treated in 14 different countries in North America, Latin Amer- ica, and Europe. Several interesting findings emerged from this study. Most important was the fact that panic disorder occurred in all the countries that were included in the study. The most prominent symptoms—choking or smothering, fear of dying, phobic avoidance—varied from one region to the next, but the overall prevalence rate appeared to be about the same.

Causes of Anxiety Disorders Now that we have discussed the various symptoms associated with anxiety disorders and their distribution within the popula- tion, we can consider the origins of these disorders. How do these problems develop? Going back to the case that was presented at the beginning of the chapter, what might account for the onset of Johanna’s panic attacks?

Adaptive and Maladaptive Fears Current theories regarding the causes of anxiety disorders often focus on the evolutionary significance of anxiety and fear. These emotional response systems are clearly adaptive in many situ- ations. They mobilize responses that help the person survive in the face of both immediate dangers and long-range threats. An evolutionary perspective helps to explain why human beings are vulnerable to anxiety disorders, which can be viewed as problems that arise in the regulation of these necessary response systems (Hofer, 2010). The important question is not why we experi- ence anxiety, but why it occasionally becomes maladaptive. When anxiety becomes excessive, or when intense fear is triggered at an inappropriate time or place, these response systems can become more harmful than helpful. In order to understand the develop- ment of anxiety disorders, we must consider a variety of psycho- logical and biological systems that have evolved for the purpose of triggering and controlling these alarm responses.

Should we expect to find unique causal pathways associ- ated with each of the types of anxiety disorder listed in DSM-5? This seems unlikely, particularly in light of the extensive over- lap among the various subtypes. Should we expect that all the different types of anxiety disorders are produced by the same causes? This also seems unlikely, and an evolutionary perspective suggests that a middle ground between these two extremes may provide the most useful explanation (Marks & Nesse, 1994). Generalized forms of anxiety probably evolved to help the per- son prepare for threats that could not be identified clearly. More

The diagnosis of anxiety disorders among elderly people is complicated by the need to consider factors such as medical ill- nesses and other physical impairments and limitations (Carmin & Ownby, 2010). Respiratory and cardiovascular problems may resemble the physiological symptoms of a panic attack. Hearing losses may lead to anxiety in interpersonal interactions. Subse- quent avoidance might be inappropriately attributed to the onset of social anxiety disorder. A frail elderly person who falls down on the street may become afraid to leave home alone, but this may be a reasonable concern rather than a symptom of agoraphobia. For reasons such as these, the diagnosis of anxiety disorders must be done with extra caution in elderly men and women.

Cross-Cultural Comparisons People in different cultures express anxiety in different ways (see the description of ataques de nervios in Chapter 4 on page 84). As in the case of depression, people in nonwestern cultures are more likely to communicate their anxiety in the form of somatic complaints, such as “My chest hurts,” “I can’t breathe,” or “I’m tired and restless all the time” (Halbreich et al., 2007; Hoge et al., 2006). The primary focus of anxiety complaints also varies con- siderably across cultural boundaries. In other words, we need to consider the kinds of situations that provoke intense anxiety as well as the ways in which we recognize that a person is anxious. People in Western societies often experience anxiety in relation to their work performance, whereas in other societies people may be more concerned with family issues or religious experiences. In the Yoruba culture of Nigeria, for example, anxiety is frequently as- sociated with fertility and the health of family members (Good & Kleinman, 1985).

Anxiety disorders have been observed in preliterate as well as Westernized cultures. Of course, the same descriptive and diagnos- tic terms are not used in every culture, but the basic psychological phenomena appear to be similar (Draguns & Tanaka-Matsumi,

Heavy drinkers are more likely than other people to develop anxiety disorders, and people who are highly anxious are more likely to start to drink heavily.

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 153

and physical abuse (being physically beaten or threatened with violence). Children who are exposed to higher levels of adversity are more likely to develop anxiety disorders later in their lives (Moffitt et al., 2007; Phillips et al., 2005).

Evidence regarding childhood adversity and the development of psychopathology points, once again, to similarities between depression and anxiety. Keep in mind that there is substantial overlap in these disorders; people who meet criteria for anxi- ety disorders also frequently meet criteria for major depression. Those who are exposed to parental abuse, neglect, and violence are more vulnerable to the development of both anxiety disorders and major depression (Kessler et al., 2008; Lara & Klein, 1999). There does not seem to be a direct connection between particular forms of adverse environmental events and specific types of mental disorders.

ATTACHMENT RELATIONSHIPS AND SEPARATION ANXIETY The evidence regarding childhood adversity is similar to another perspective on the origins of anxiety disorders that has been concerned with the infant’s attachment relationship with caretakers. Attachment theory (see Chapter 2) integrates the psy- chodynamic perspective with field observations of primate behav- ior and with laboratory research with human infants. According to the British psychiatrist John Bowlby (1973, 1980), anxiety is an innate response to separation, or the threat of separation, from the caretaker. Those infants who are insecurely attached to their parents are presumably more likely to develop anxiety disorders, especially agoraphobia, when they become adults.

Several studies have found that people with a variety of anxi- ety disorders are more likely to have had attachment problems as children (Cassidy & Mohr, 2001; Dozier et al., 2008; Lewinsohn et al., 2008). Anxious attachment as infants may make these

specific forms of anxiety and fear probably evolved to provide more effective responses to certain types of danger. For example, fear of heights is associated with a freezing of muscles rather than running away, which could lead to a fall. Social threats are more likely to provoke responses such as shyness and embarrassment that may increase acceptance by other people by making the individual seem less threatening. Each type of anxiety disorder can be viewed as the dysregulation of a mechanism that evolved to deal with a particular kind of danger. This model leads us to expect that the etiological pathways leading to various forms of anxiety disorders may be partially distinct but not completely independent.

Social Factors Stressful life events, particularly those involving danger and inter- personal conflict, can trigger the onset of certain kinds of anxiety disorders. For example, various aspects of parent–child relation- ships may leave some people more vulnerable to the development of anxiety disorders when they become adults. Taken together, the evidence bearing on these issues helps explain the relationship between, and the overlap among, anxiety disorders and mood disorders.

STRESSFUL LIFE EVENTS Common sense suggests that people who experience high stress levels are likely to develop negative emotional reactions, which can range from feeling “on edge” to the onset of full-blown panic attacks. In Chapter 5 we reviewed the literature concerning stressful life events and depression. Sev- eral investigations suggest that stressful life events can influence the onset of anxiety disorders as well as depression. Patients with anxiety disorders are more likely than other people to report hav- ing experienced a negative event in the months preceding the ini- tial development of their symptoms (Kendler et al., 2003).

Why do some negative life events lead to depression while others lead to anxiety? The nature of the event may be an impor- tant factor in determining the type of mental disorder that ap- pears (McLaughlin & Hatzenbuehler, 2009; Updegraff & Taylor, 2000). People who develop an anxiety disorder are much more likely to have experienced an event involving danger, insecurity, or family discord, whereas people who are depressed are more likely to have experienced a severe loss (lack of hope). Different types of environmental stress lead to different types of emotional symptoms.

CHILDHOOD ADVERSITY If recent dangers and conflicts can precipitate the full-blown symptoms of an anxiety disorder, do past experiences—those that took place years ago—set the stage for this experience? Several research studies indicate that they can (Harkness & Wildes, 2002). Studies of these phenomena focus on measures of childhood adversity. This concept includes expe- riences such as maternal prenatal stress, multiple maternal part- ner changes, parental indifference (being neglected by parents),

Japanese women react with fear as rescue workers check for radiation contamination following a massive earthquake that damaged a nuclear reactor.

154 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

conscious awareness. They are also highly selective, in the sense that the module is particularly responsive to a narrow range of stimuli. Human beings seem to be prepared to develop intense, persistent fears only to a select set of objects or situations. Fear of these stimuli may have conferred a selective advantage upon those people—hundreds of thousands of years ago—who were able to develop fears and consequently avoid certain kinds of dangerous stimuli, such as heights, snakes, and storms. This is not to say that the fears are innate or present at birth, but rather that they can be learned and maintained very easily.

Many investigations have been conducted to test various fac- ets of this preparedness model (Mineka & Oehlberg, 2008). The results of these studies support many features of the theory. For example, conditioned responses to fear-relevant stimuli (such as spiders and snakes) are more resistant to extinction than are those to fear-irrelevant stimuli (such as flowers). Furthermore, it is possible to develop conditioned fear responses after only one trial of learning.

The process of prepared conditioning may play an impor- tant role in the development of both specific phobias and social anxiety disorder. In specific phobias, the prepared stimuli are things like snakes, heights, storms, and small enclosed places. The prepared stimulus in social anxiety disorder might involve other people’s faces. We are prepared to fear faces that appear an- gry, critical, or rejecting if they are directed toward us (Öhman, 1996). This process is presumably an evolutionary remnant of factors involved in establishing dominance hierarchies, which maintain social order among primates. Animals that are defeated in a dominance conflict are often allowed to remain as part of the group if they behave submissively. The responses of people with social anxiety disorder may be somewhat analogous, in the sense that they are afraid of directly facing, or being evaluated by, other people. When a performer makes eye contact with his or her au- dience, an association may develop very quickly between fear and angry or critical facial expressions.

We all learn many behaviors through imitation. Albert Bandura’s early work on modeling, for example, demonstrated that children who observe a model hitting a doll are more likely to behave aggressively themselves when given the opportunity (see Chapter 2). Similar processes may also affect the development of intense fear, because some phobias develop in the absence of any direct experience with the feared object. People apparently learn to avoid certain stimuli if they observe other people showing a strong fear response to those stimuli (Poulton & Menzies, 2002). In other words, the traumatic event does not have to happen to you; it may be enough for you to witness a traumatic event hap- pening to someone else or to watch someone else behave fearfully.

COGNITIVE FACTORS Up to this point, we have talked about the importance of life events and specific learning experiences— variables that can be measured outside the organism. But

individuals more vulnerable, once they are adults, to the threats that are contained in interpersonal conflict, for example, loss of a loved one if a marriage dissolves. This hypothesis fits nicely with the observation that interpersonal conflict is a relatively frequent triggering event for the onset of agoraphobic symptoms. There is also an interesting connection between attachment styles and childhood adversity. People who report childhood adversities in- volving interpersonal trauma (assault, abuse, neglect) are more likely to be insecurely attached, and they are also more vulnerable to depression and anxiety (Mickelson, Kessler, & Shaver, 1997).

Psychological Factors Research suggests that stressful life events and childhood adversity contribute to the development of anxiety disorders. But what are the specific mechanisms that link these experiences to emo- tional difficulties, such as intense fears, panic attacks, and ex- cessive worry? This question brings our discussion of causes to a different level of analysis. A number of psychological mecha- nisms undoubtedly play important roles in helping to shape the development and maintenance of anxiety disorders. They include learning processes and cognitive events.

LEARNING PROCESSES Since the 1920s, experimental psychol- ogists working in laboratory settings have been interested in the possibility that specific fears might be learned through classical (or Pavlovian) conditioning (Ayres, 1998). The central mechanism in the classical conditioning process is the association between an unconditioned stimulus (US) and a conditioned stimulus (CS). The US is able to elicit a strong unconditioned emotional re- sponse (UR), such as fear. Examples of potential USs are painfully loud and unexpected noises, the sight of dangerous animals, and sudden, intense pain. According to psychologists’ original views of the classical conditioning process, the CS could be any neu- tral stimulus that happened to be present when an intense fear reaction was provoked. Through the process of association, the CS would subsequently elicit a conditioned response (CR), which was similar in quality to the original UR (see Chapter 2). This explanation for the development of specific phobias fits easily with common sense as well as with clinical experience. Many intense, persistent, irrational fears seem to develop after the person has experienced a traumatic event (Merckelbach, Muris, & Schouten, 1996).

Current views on the process by which fears are learned sug- gest that the process is guided by a module, or specialized circuit in the brain, that has been shaped by evolutionary pressures (Öhman & Mineka, 2001). Some psychologists have argued that the mind includes a very large number of prepared modules (spe- cialized neural circuits) that serve particular adaptive functions, such as the recognition of faces and the perception of language (Pinker, 1997). These modules are designed to operate at maxi- mal speed, are activated automatically, and perform without

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 155

enhancing the person’s sense of threat, and so on, until the pro- cess spirals out of control. Thus, both cognitive misinterpretation and biological reactions associated with the perception of threat are necessary for a panic attack to occur.

The person’s automatic, negative thoughts may also lead him to engage in behaviors that are expected to increase his safety, when in fact they are counterproductive. For example, some peo- ple believe that they should take deep breaths or monitor their heart rate if they become aroused. This is actually incorrect in- formation, and the alleged safety behaviors can further exaggerate the person’s fear response.

Many research studies have found that the subjective experi- ence of body sensations is, in fact, closely associated with mal- adaptive or catastrophic thoughts among patients with panic disorder (McNally, 1994). This connection by itself does not provide strong evidence for a causal link between catastrophic thoughts and the onset of panic attacks because catastrophic thoughts (such as fear of losing control and fear of dying) are, in fact, part of the definition of a panic attack (see DSM5: Diagnostic Criteria for Panic Disorder). The theory is difficult to test (cannot be disproven) if there is no way to separate the mea- surement of catastrophic thoughts and the panic attack itself (Roth, Wilhelm, & Pettit, 2005).

Catastrophic misinterpretations cannot account for all in- stances of panic attacks. For example, patients with panic disor- der sometimes experience panic attacks in their sleep (Craske & Rowe, 1997). How could that happen if the escalation to panic requires catastrophic misinterpretation of physical sensations, which presumably involves conscious cognitive processes? Clearly, other factors are also involved. One alternative explanation in- volves classical conditioning. The experience of an initial panic attack might lead to conditioned anxiety to cues associated with the first attack. These could be either internal bodily sensations or external stimuli. The conditioned anxiety might lower the per- son’s threshold for subsequent panic attacks (Bouton, Mineka, & Barlow, 2001).

ATTENTION TO THREAT AND BIASED INFORMATION PRO- CESSING Earlier in this chapter we mentioned that anxiety involves negative thoughts and images anticipating some pos- sible future danger. In recent years, several lines of research have converged to clarify the basic cognitive mechanisms involved in generalized anxiety disorder as well as panic disorder. Experts now believe that attention plays a crucial role in the onset of this process. People who are prone to excessive worrying and panic are unusually sensitive to cues that signal the existence of future threats (MacLeod et al., 2002; Teachman, Smith-Janik, & Saporito, 2007). They attend vigilantly to even fleeting signs of danger, especially when they are under stress. At such times, the recognition of danger cues triggers a maladaptive, self- perpetuating cycle of cognitive processes that can quickly spin out of control.

cognitive events also play an important role as mediators between experience and response. Perceptions, memory, and attention all influence the ways that we react to events in our environments. It is now widely accepted that these cognitive factors play a cru- cial role in the development and maintenance of various types of anxiety disorders. We will focus on three aspects of this literature: perception of controllability and predictability, catastrophic mis- interpretation (panic attacks), and attentional biases and shifts in the focus of attention.

PERCEPTION OF CONTROL There is an important relation- ship between anxiety and the perception of control. People who believe that they are able to control events in their environment are less likely to show symptoms of anxiety than are people who believe that they are helpless. This is, of course, part of the reason that the events of September 11, 2001 were so terrifying. The attack on the World Trade Center in New York City was beyond the control of its victims, who were going about their everyday activities.

An extensive body of evidence supports the conclusion that people who believe that they are less able to control events in their environment are more likely to develop global forms of anxiety (Andrews, 1996), as well as various specific types of anxiety disorders (Mineka & Zinbarg, 1998). Laboratory research indicates that feelings of lack of control contribute to the onset of panic attacks among patients with panic disorder. The perception of uncontrollability has also been linked to the submissive behavior frequently seen among people with social anxiety disorder as well as the chronic worries of people with gen- eralized anxiety disorder.

CATASTROPHIC MISINTERPRETATION A somewhat different type of cognitive dysfunction has been discussed extensively with relation to the development of panic disorder. According to this view, panic disorder may be caused by the catastrophic misinter- pretation of bodily sensations or perceived threat (D. M. Clark, 1986; L. A. Clark, 1999). Although panic attacks can be precipi- tated by external stimuli, they are usually triggered by internal stimuli, such as bodily sensations, thoughts, or images. On the basis of past experience, these stimuli initiate an anxious mood, which leads to a variety of physiological sensations that typically accompany negative emotional reactions (changes in heart rate, respiration rate, dizziness, and so on). Anxious mood is accom- panied by a narrowing of the person’s attentional focus and an increased awareness of bodily sensations.

The crucial stage comes next, when the person misinterprets the bodily sensation as a catastrophic event. For example, a person who believes that there is something wrong with his heart might misinterpret a slight acceleration in heart rate as being a sign that he is about to have a heart attack. He might say to himself, “My heart will stop and I’ll die!” This reaction ensures the contin- ued operation of this feedback loop, with the misinterpretation

156 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

(in practice) cannot perform it in front of an audience. This deterioration in skill may be caused by anxious apprehension, which is similar to the cognitive processes involved in worrying (Barlow, 2004). The cycle is illustrated in Figure 6.1. An increase in negative affect presumably triggers a shift toward self-focused attention (“Oh, no, I’m getting really upset”) and activates cog- nitive biases and threat schemas (“What if I make a mistake?”). The person becomes distracted by these thoughts, and perfor- mance deteriorates. In a sense, the person’s fearful expectations become a self-fulfilling prophesy (Heerey & Kring, 2007).

Biological Factors Several pieces of evidence indicate that biological events play an important role in the development and maintenance of anxiety disorders. In the following pages we review the role of genetic fac- tors, the connection between anxiety symptoms and specific re- gions in the brain, and the use of chemicals to induce symptoms of panic. These factors undoubtedly interact with the social and psychological variables that we have considered in the preceding sections.

GENETIC FACTORS Some of the most useful information about the validity of anxiety disorders comes from studies aimed at identifying the influence of genetic factors. These data address the overlap, as well as the distinctions, among various types of anxiety disorders. They also shed additional light on the relation- ship between anxiety and depression.

One particularly influential study, known as the “Virginia Adult Twin Study,” has examined anxiety disorders—as well as

The threatening information that is generated in this pro- cess is presumably encoded in memory in the form of elabo- rate schemas, which are easily reactivated. The threat schemas of anxious people contain a high proportion of “what-if ” ques- tions, such as “What am I going to do if I don’t do well in school this semester?” Once attention has been drawn to threatening cues, the performance of adaptive, problem-solving behaviors is disrupted, and the worrying cycle launches into a repetitive sequence in which the person rehearses anticipated events and searches for ways to avoid them. This process activates an ad- ditional series of “what-if ” questions that quickly leads to a dramatic increase in negative affect (McLaughlin, Borovec, & Sibrava, 2007).

If worriers are preoccupied with the perception of threat cues and the rehearsal of dangerous scenarios but are unable to reach satisfactory solutions to their problems, why do they continue to engage in this vicious, maladaptive cycle? Two considerations are particularly important in explaining the self-perpetuating nature of worry: (1) Worry is an experience that is made up of “self-talk”—things that people say to themselves rather than visual images (“I’ll never get all this work done!”). (2) Worry serves the function of avoiding unpleasant somatic activation through the suppression of imagery (Borkovec, Alcaine, & Behar, 2004). In other words, some people apparently continue to worry, even though it is not productive, because worrying is reinforced by an immediate (though temporary) reduction in uncomfortable physiological sensations.

Attentional mechanisms also seem to be involved in the eti- ology and maintenance of social anxiety disorder. People who are capable of performing a particular task when they are alone

FIGURE 6.1 Anxious Apprehension and Social Phobia Processes involved in the generation of social anxiety. Source: Based on Barlow, David. 2004. Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic. Guilford Press.

ANXIETY-PROVOKING SITUATION

FURTHER INCREASE IN AROUSALDYSFUNCTIONAL PERFORMANCE

ATTEMPTS TO COPE BY:

NEGATIVE AFFECT including sense of uncontrollability

COGNITIVE BIASES AND HYPERVIGILANCE enhanced attention to threat cues

ATTENTIONAL SHIFT to self-evaluative focus

AVOIDANCE of situation

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 157

evolved fear module for conditioned fear. The message follows a direct connection between the thalamus and the amygdala, which is connected to the hypothalamus. Behavioral responses (such as the “fight-or-flight” response) are then activated and coordinated through projections from the hypothalamus to endocrine glands and the autonomic nervous system (see Chapter 2, as well as the discussion of the HPA axis in Chapter 5). Notice that this first pathway does not involve connections to cortical areas of the brain that might involve higher-level cognitive functions such as conscious memory or decision making. The amygdala does store unconscious, emotional memories—the kind that are generated through prepared learning.

A second, complementary path from the thalamus (the pur- ple arrow) leads to the cortex and provides for a detailed, and comparatively slower, analysis of the information that has been detected. Using the example in Figure 6.2, information about the snake would be sent to the visual cortex. Once the pattern is recognized as a snake, the data would be integrated with ad- ditional information from memory about its emotional signifi- cance (“potentially dangerous”). This message would then be sent to the amygdala, which could, in turn, trigger an organized re- sponse to threat. This second pathway is longer and more com- plex than the first, and it will take longer to generate a response. The first pathway has presumably evolved because it is adaptive; it provides the organism with an alarm system that can be used to avoid immediate dangers in the environment. The fact that information can follow either path is consistent with the idea that some fear responses are “hardwired” (easily learned, difficult to extinguish, and mediated by unconscious processes) while others are dependent on higher-level analyses that involved thinking and reasoning.

A word of caution must be added when we consider the functions of these specific neural pathways. The fact that they are involved in processing fearful reactions does not mean that the amygdala and associated structures are exclusively dedicated to this particular purpose. Studies with animals have shown that artificial stimulation of the amygdala can produce different effects, depending in large part on the environmental context in which the animal is stimulated (Kagan, 1998). Anger, disgust, and sexual arousal are all emotional states that are associated with activity in pathways connecting the thalamus, the amygdala, and their pro- jections to other brain areas. Fear responses are, therefore, only one of the many kinds of behavior associated with these circuits.

The brain regions that have been identified in studies of fear conditioning play an important role in phobic disorders and panic disorder (Etkin & Wager, 2007; Ninan & Dunlop, 2005). In the case of panic disorder, the fear module may be triggered at an inappropriate time. The sensitivity of this pathway is not the same in all people, and it is presumably influenced by genetic factors as well as hormone levels. Social and psychological fac- tors that affect the threshold of the fear module include stress- ful life events and the development of separation anxiety during

many other forms of psychopathology—in a large sample of twins (Kendler & Prescott, 2006). The people who participated in this study were not psychiatric patients; they were living in the community and were identified through a statewide registry of twins born in Virginia. For each specific type of anxiety dis- order, concordance rates were significantly higher for monozy- gotic (MZ) twins than for dizygotic (DZ) twins. Nevertheless, the MZ concordance rates were also relatively low (in compari- son to MZ concordance rates for bipolar disorders, for exam- ple). Anxiety disorders appear to be modestly heritable, with genetic factors accounting for between 20 and 30 percent of the variance in the transmission of GAD. (See Research Methods in Chapter 16 for a discussion of heritability.) These results led the investigators to several important conclusions:

1. Genetic risk factors for these disorders are neither highly specific (a different set of genes being associated with each disorder) nor highly nonspecific (one common set of genes causing vulnerability for all disorders).

2. Two genetic factors have been identified: one associated with GAD, panic disorder, and agoraphobia, and the other with specific phobias.

3. Environmental risk factors that would be unique to individu- als also play an important role in the etiology of all anxiety disorders. Environmental factors that would be shared by all members of a family do not seem to play an important role for many people.

NEUROBIOLOGY Laboratory studies of fear conditioning in animals have identified specific pathways in the brain that are responsible for detecting and organizing a response to danger (LeDoux, 2000; Öhman & Mineka, 2003). The amygdala plays a central role in these circuits, which represent the biological un- derpinnings of the evolved fear module that we discussed ear- lier in connection with classical conditioning and phobias (see pages 154–155). Scientists have discovered these pathways by monitoring and manipulating brain activities in animals that are participating in studies using classical conditioning to pair an originally neutral stimulus (the CS) with an aversive stimu- lus (the US). The results of these studies tell us where emotional responses, such as fear and panic, are located in terms of brain regions. They also begin to explain how they are produced. That knowledge, coupled with data regarding social and psychological factors, will help us understand why people experience problems such as irrational fears and panic attacks.

The brain circuits involved in fear conditioning are illustrated in Figure 6.2. This drawing uses the example of a person who has seen a dangerous snake (Carter, 1999). Sensory information is projected to the thalamus, and from there it is directed to other brain areas for processing. Emotional stimuli follow two primary pathways, both of which lead to the amygdala. The first pathway (the red arrow) might be called a “shortcut” and represents the

158 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

and GABA are inhibitory neurotransmitters that function to dampen stress responses. Pharmacological and environmental challenges that increase their availability lead to decreased levels of anxiety. Conversely, experiences that reduce levels of serotonin and GABA can provoke increases in fear and anxiety.

Treatment of Anxiety Disorders Anxiety disorders are one of the areas of psychopathology in which clinical psychologists and psychiatrists are best prepared to improve the level of their clients’ functioning (see Getting Help).

Psychological Interventions Psychoanalytic psychotherapy has been used to treat patients with anxiety disorders since Freud published his seminal papers at the turn of the twentieth century. The emphasis in this type of treat- ment is on fostering insight regarding the unconscious motives that presumably lie at the heart of the patient’s symptoms. Although

childhood (which increases the rate of panic disorder when these children become adults). The subcortical pathway between the thalamus and the amygdala may be responsible for the misin- terpretation of sensory information, which then triggers the hypothalamus and activates a variety of autonomic processes (dramatic increases in respiration rate, heart rate, and so on). Some investigators have also speculated that this brain circuit may be associated with the biased attention to threat cues that has been demonstrated in patients with various types of anxiety disorders (Bishop, 2007).

Several different neurotransmitters are responsible for com- munication in the brain regions that regulate emotion. Their role in the development and maintenance of anxiety disorders has been examined in studies of animal models of anxiety (Pohl et al., 2007) as well as in studies of the impact of medications on human behavior (Kalueff & Nutt, 2007). Perhaps most important with regard to the anxiety disorders are serotonin, norepinephrine, gamma-aminobutyric acid (GABA), and dopamine. Serotonin

FIGURE 6.2 Two Pathways in the Brain That Detect Danger and Trigger Fear Responses (1) Evolved fear module, and (2) slower, indirect route through cortical processing areas. Source: Based on Carter, Rita. 1998. Mapping the Mind. Berkeley: University of California Press.

(1) Thalamus receives stimulus and shunts it to amygdala and visual cortex

(3) Amygdala triggers fast physical action

(2) Amygdala registers danger

(4) A clear image of a snake is sent to the conscious brain for considered response

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 159

better than imaginal exposure. A few prolonged exposures can be as effective as a larger sequence of brief exposures. Another varia- tion on exposure procedures, known as flooding, begins with the most frightening stimuli rather than working up gradually from the bottom of the hierarchy. All of these variations on the basic procedure have been shown to be effective in the treatment of phobic disorders (Barlow, Raffa, & Cohen, 2002).

The treatment of panic disorder often includes two specific forms of exposure. One, situational exposure, is used to treat ago- raphobic avoidance (Hahlweg et al., 2001). In this procedure, the person repeatedly confronts the situations that have previously been avoided. These often include crowded public places, such as shopping malls and theaters, as well as certain forms of transpor- tation, such as buses and trains.

Interoceptive exposure, the other form of exposure, is aimed at reducing the person’s fear of internal, bodily sensations that are frequently associated with the onset of a panic attack, such as increased heart and respiration rate and dizziness. The process is accomplished by having the person engage in standardized exer- cises that are known to produce such physical sensations. These may include spinning in a swivel chair, running in place, breath- ing through a narrow straw, or voluntary hyperventilation, de- pending on the type of sensation that the person fears and avoids. Outcome studies indicate that interoceptive exposure is one of the most important ingredients in the psychological treatment of panic disorder (Barlow et al., 2002; Meuret et al., 2005).

many therapists continue to employ this general strategy, it has not been shown to be effective in controlled outcome studies.

SYSTEMATIC DESENSITIZATION AND INTEROCEPTIVE EX- POSURE Like psychoanalysis, behavior therapy was initially developed for the purpose of treating anxiety disorders, espe- cially specific phobias. The first widely adopted procedure was known as systematic desensitization (see Chapter 3). In desensitization, the client is first taught progressive muscle re- laxation. Then the therapist constructs a hierarchy of feared stimuli, beginning with those items that provoke only small amounts of fear and progressing through items that are most frightening. Then, while the client is in a relaxed state, he or she imagines the lowest item on the hierarchy. The item is presented repeatedly until the person no longer experiences an increase in anxiety when thinking about the object or situation. This pro- cess is repeated several times as the client moves systematically up the hierarchy, sequentially confronting images of stimuli that were originally rated as being more frightening.

In the years since systematic desensitization was originally proposed, many different variations on this procedure have been employed. The crucial feature of the treatment involves system- atic maintained exposure to the feared stimulus (McNally, 2007; Rachman, 2002). Positive outcomes have been reported, regard- less of the specific manner in which exposure is accomplished. Some evidence indicates that direct (“in vivo”) exposure works

Exposure treatments can be administered in imagina- tion, in the person’s natural environment, or using virtual reality designs. This man is being treated for fear of fly- ing in a computerized flight simulator.

160 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

A second aspect of Barlow’s cognitive component for panic patients is called decatastrophizing. In this procedure, the thera- pist asks the client to imagine what would happen if his or her worst-case scenario actually happened. The same principles that are used in examining faulty logic are then applied to this situ- ation. The therapist might say, “I don’t think that you will fail the exam. But what would happen if you did fail the exam?” The client’s initial reaction might be catastrophic (“I would die.” “My parents would kill me.” “I would flunk out of school.”). Upon more careful analysis, however, the client might agree that these negative predictions actually represent gross exaggerations that are based on cognitive errors. Discussions in the therapy session are followed by extensive practice and homework assignments during the week. As one way of evaluating the accuracy of their own hypotheses, clients are encouraged to write down predictions that they make about specific situations and then keep track of the actual outcomes.

Several controlled outcome studies attest to the efficacy of cognitive therapy in the treatment of various types of anxi- ety disorders, including panic disorder, agoraphobia, social anxiety disorder, and generalized anxiety disorder (Hofmann et al., 2012). Most of these patients experience clinically im- portant benefits (see Research Methods). Improvement in symptoms over time seems to be preceded by changes in cog- nitive processing. This observation provides support for the hypothesis that cognitive factors do play an important role in maintenance of these disorders (Teachman, Marker, & Smith-Janik, 2009).

Biological Interventions Medication is the most effective and most commonly used bio- logical approach to the treatment of anxiety disorders. Several types of drugs have been discovered to be useful. They are often used in conjunction with psychological treatment (Otto, Smits, & Reese, 2004; Vanin, 2008).

ANTIANXIETY MEDICATIONS The most frequently used types of minor tranquilizers are from the class of drugs known as ben- zodiazepines, which includes diazepam (Valium) and alprazolam (Xanax). These drugs reduce many symptoms of anxiety, es- pecially vigilance and subjective somatic sensations, such as in- creased muscle tension, palpitations, increased perspiration, and gastrointestinal distress. They have relatively less effect on a per- son’s tendency toward worry and rumination. Benzodiazepines were the most widely prescribed form of psychiatric medication until the 1990s.

Benzodiazepines bind to specific receptor sites in the brain that are ordinarily associated with a neurotransmitter known as GABA. Benzodiazepines, which enhance the activity of GABA neurons, are of two types, based on their rate of absorption and elimination from the body. Some, such as alprazolam and loraz- epam (Ativan), are absorbed and eliminated quickly, whereas others, such as diazepam, are absorbed and eliminated slowly.

RELAXATION AND BREATHING RETRAINING Behavior thera- pists have used relaxation procedures for many years. Relaxation training usually involves teaching the client alternately to tense and relax specific muscle groups while breathing slowly and deeply. This process is often described to the client as an active coping skill that can be learned through consistent practice and used to control anxiety and worry.

Outcome studies indicate that relaxation is a useful form of treatment for various forms of anxiety disorder (Arntz, 2003; Siev & Chambless, 2007). For example, applied relaxation and cognitive behavior therapy have been compared to nondirective psychotherapy for the treatment of patients with generalized anx- iety disorder. Patients who received relaxation training and those who received cognitive therapy were more improved at the end of treatment than those who received only nondirective therapy (Borkovec et al., 2002).

Breathing retraining is a procedure that involves education about the physiological effects of hyperventilation and practice in slow breathing techniques. It is often incorporated in treatments used for panic disorder (Hazlett-Stevens & Craske, 2009). This process is similar to relaxation in the sense that relaxation exer- cises also include instructions in breathing control. The person learns to control his or her breathing through repeated practice using the muscles of the diaphragm, rather than the chest, to take slow, deep breaths. Although breathing retraining appears to be a useful element in the treatment of panic disorder, the mecha- nisms involved are not entirely clear. A simple reduction in the frequency of hyperventilation is apparently not the main effect of breathing retraining. Some clinicians believe that the process works by enhancing relaxation or increasing the person’s percep- tion of control.

COGNITIVE THERAPY Cognitive therapy is used extensively in the treatment of anxiety disorders. Cognitive treatment pro- cedures for anxiety disorders are similar to those employed in the treatment of depression. Therapists help clients identify cognitions that are relevant to their problem; recognize the re- lation between these thoughts and maladaptive emotional re- sponses (such as prolonged anxiety); examine the evidence that supports or contradicts these beliefs; and teach clients more useful ways of interpreting events in their environment (Schuy- ler, 1991).

In the case of anxiety disorders, cognitive therapy is usually accompanied by additional behavior therapy procedures. Barlow’s approach to the treatment of panic disorder, for example, in- cludes a cognitive component in addition to applied relaxation and exposure (Barlow, 1997). One aspect of the cognitive com- ponent involves an analysis of errors in the ways in which people think about situations in their lives. Typical examples of faulty logic include jumping to conclusions before considering all of the evidence, overgeneralizing (“That C in biology shows I’ll never be a doctor”), “all-or-none” thinking (assuming that one mistake means total failure), and so on.

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 161

some psychiatrists to be the drug of choice for patients with this condition because it produces clinical improvement more quickly than antidepressants.

Many patients with panic disorder and agoraphobia relapse if they discontinue taking medication (Marks et al., 1993). Exposure may be a preferable form of treatment for patients with a diagnosis of panic disorder with agoraphobia because of high relapse rates that have been observed after alprazolam is withdrawn.

Benzodiazepines have been shown to be effective in the treat- ment of generalized anxiety disorders and social anxiety disorder (Ballenger, 2001; Benitez et al., 2008). Drug effects are most consistently evident early in treatment. The long-term effects of benzodiazepines (beyond six months of treatment) are not well established (Mahe & Balogh, 2000). They are not typically ben- eficial for patients with specific phobias. Certain high-potency benzodiazepines are also useful for treating panic disorder (Spiegel & Bruce, 1997). Alprazolam (Xanax) is considered by

RESEARCH methods

Statistical Significance: When Differences Matter

Let’s say that an outcome study reveals a statistical differ-ence in the effectiveness of one form of treatment versus another form (or no treatment at all). Does this automati- cally mean that the difference is clinically significant? The answer is no. We can explain this point by using a hypothetical example. Imagine that you want to know whether exposure and response prevention are effective in the treatment of OCD. You could conduct a study, using an experimental design, in which 50 patients with OCD are randomly assigned to receive exposure and response prevention and another 50 patients—the control group—are not. The latter group might receive a placebo pill or nondirective supportive psychotherapy for purposes of com- parison. Measures of obsessions and compulsions are collected before and after treatment for patients in both groups. Your hypothesis is that exposure treatment will lead to more improve- ment than will placebo or nondirective therapy. In contrast, the null hypothesis (see Research Methods in Chapter 1) holds that the two forms of treatment are not truly different. To conclude that exposure and response prevention are effective, you must reject the null hypothesis.

After collecting your data, you can use statistical tests to help you decide whether you can reject the null hypothesis. These tests assign a probability to that result, indicating how often we would find that result if there are not really differences between the two treatments. Psychologists have adopted the .05 level, meaning that if a difference occurs only by chance, you would find this difference less than five times out of every 100 times you repeated this experiment. Differences that exceed the .05 level, therefore, are assumed to reflect real differences between the variables rather than mere chance. Such results are said to be statistically significant.

Statistical significance should not be equated with clinical impor- tance (Jacobson & Truax, 1991; Lambert, Hansen, & Bauer, 2008). It is possible for an investigator to find statistically significant differences between groups (and therefore reject the null hy- pothesis) on the basis of relatively trivial changes in the patients’ adjustment. Consider the hypothetical example outlined above

and suppose that you measured outcome in terms of a question- naire for obsessions and compulsions whose scores could range from 0 (no symptoms) to 100 (highest score possible). Let’s also assume that the average person without OCD gets a score of 50 on this questionnaire and that a score of 70 or higher is typically considered to indicate the presence of problems that are associ- ated with a disruption of the person’s social and occupational functioning. Both groups have a mean rating of 90 on the scale prior to treatment. At the end of treatment, the mean rating for the exposure group has dropped to 75, and the mean for the control group is now 85. If you have included enough subjects, and depending on the amount of variation among scores within each group, this difference might reach statistical significance. But is it clinically important? Probably not. The average patient in the exposure group still has a score above the cutoff for identify- ing meaningful levels of psychopathology and 25 points above the average for adults in the general population.

Clinical importance is sometimes measured in terms of the pro- portion of people in the treatment group whose outcome scores fall below a certain threshold of severity or within the range of scores that are produced by people without the disorder in question. In the case of OCD, people treated with exposure and response prevention do show levels of change that are considered clinically important as well as statistically significant (Abramowitz, 1998).

Clinical investigators should also consider the kind of changes that they expect to find as well as the amount of change. In ad- dition to looking at changes in particular symptoms, such as a reduction in the frequency of compulsive behaviors, some clini- cal investigators also ask questions about the patient’s quality of life (Gladis et al., 1999). These include an interest in the person’s overall satisfaction as well as his or her ability to perform various social roles, at work, at school, or with friends and family. Thera- pists obviously hope that their patients will experience improve- ments in their overall quality of life and level of social adjustment when they are able to achieve a reduction in the severity of symptoms of mental disorders.

162 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

including weight gain, dry mouth, and overstimulation (some- times referred to as an “amphetamine-like” response). Some of the side effects (like feeling jittery, nervous, lightheaded, and hav- ing trouble sleeping) are upsetting to patients because they re- semble symptoms of anxiety. Side effects often lead patients to discontinue treatment prematurely.

In actual practice, anxiety disorders are often treated with a combination of psychological and biological procedures. The se- lection of specific treatment components depends on the specific group of symptoms that the person exhibits. The potential ben- efits and costs of combined treatment with medication and psy- chological procedures should be studied more carefully. Current evidence suggests that patients who receive both medication and psychotherapy may do better in the short run, but patients who receive only cognitive behavior therapy may do better in the long run because of difficulties that can be encountered when medica- tion is discontinued (Otto et al., 2005).

Obsessive-Compulsive and Related Disorders Obsessive-compulsive disorder (OCD) is one of the most de- bilitating disorders in the world, including all kinds of medi- cal disorder (see Figure 1.2 on page 13). OCD was listed as a form of anxiety disorder in previous editions of the diagnostic manual (see Thinking Critically about DSM-5 on page 149). Now it is listed separately. DSM-5 devotes a separate chapter to obsessive-compulsive and related disorders. All of these disor- ders are defined by the presence of unwanted intrusive thoughts and/or habitual behaviors. In the following pages, we will dis- cuss OCD, hoarding disorder, trichotillomania, and excoriation (skin-picking) disorder. Body dysmorphic disorder is discussed in Chapter 7.

Common side effects of benzodiazepines include sedation accompanied by mild psychomotor and cognitive impairments. These drugs can, for example, increase the risk of automobile ac- cidents, because they interfere with motor skills. They can also lead to problems in attention and memory, especially among elderly patients.

The most serious adverse effect of benzodiazepines is their potential for addiction. Approximately 40 percent of people who use benzodiazepines for six months or more will exhibit symp- toms of withdrawal if the medication is discontinued (Michelini et al., 1996). Withdrawal reactions include the reappearance of anxiety, somatic complaints, concentration problems, and sleep difficulties. They are most severe among patients who abruptly discontinue the use of benzodiazepines that are cleared quickly from the system, such as alprazolam.

Another class of antianxiety medication, known as the aza- pirones, includes drugs that work on entirely different neural pathways than the benzodiazepines (Cadieux, 1996). Rather than inhibiting the activity of GABA neurons, azapirones act on serotonin transmission. The azapirone that is used most frequently in clinical use is known as buspirone (BuSpar). Placebo-controlled outcome studies indicate that buspirone is effective in the treatment of generalized anxiety disorder (Davidson et al., 1999). Some clinicians believe that buspirone is preferable to the benzodiazepines because it does not cause drowsiness and does not interact with the effects of alcohol. The disadvantage is that patients do not experience relief from severe anxiety symptoms as quickly with buspirone as they do with benzodiazepines.

ANTIDEPRESSANT MEDICATIONS The selective serotonin reuptake inhibitors (SSRIs), discussed in Chapter 5, have become the preferred form of medication for treating almost all forms of anxiety disorder. These include drugs such as fluoxetine (Pro- zac), fluvoxamine (Luvox), sertraline (Zoloft), and paroxetine (Paxil). Reviews of controlled outcome studies indicate that they are at least as effective as other, more traditional forms of anti- depressants in reducing symptoms of various anxiety disorders (Anderson, 2006; Roy-Byrne & Cowley, 2002). They also have fewer unpleasant side effects, they are safer to use, and withdrawal reactions are less prominent when they are discontinued. There- fore, the SSRIs are now considered the first-line medication for treating panic disorder and social anxiety.

Imipramine (Tofranil), a tricyclic antidepressant medication, has been used for more than 40 years in the treatment of patients with panic disorder. A large number of double-blind, placebo-con- trolled studies indicate that it produces beneficial results (Jefferson, 1997; Mavissakalian & Ryan, 1998). Psychiatrists often prefer imipramine to antianxiety drugs for the treatment of panic disorder because patients are less likely to become dependent on the drug than they are to high-potency benzodiazepines like alprazolam.

The tricyclic antidepressants are used less frequently than the SSRIs because they produce several unpleasant side effects, © Joe Dator/The New Yorker Collection/www.cartoonbank.com

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 163

strangled! He tore up the first copy and filled it out again. When it was finally done to his satisfaction, Ed sealed the form in an envelope and put it in the box for outgoing mail. After returning to his desk, he was suddenly overwhelmed by the feeling that he had indeed made a mistake with that P. If he allowed the form to be mailed, the evil image would be associated forever with his wife. Consumed by fear, Ed rushed back to the mailbox, tore up the envelope, and started a new form. Twenty minutes later, he had the form filled out and back in the mailbox. Then the cycle repeated itself. Each time, Ed became more distraught and frus- trated, until he eventually felt that he was going to lose his mind.

In addition to his problems with writing, Ed was also afraid of axes. He would not touch an ax, or even get close to one. Any situation in which he could possibly encounter an ax made him ex- tremely uncomfortable. He refused to shop in hardware stores be- cause they sell axes, and he would not visit museums because their exhibits often contain artifacts such as medieval armor. His fear of axes was quite specific. Ed wasn’t afraid of knives, guns, or swords.

One frightening experience seemed to trigger the pervasive anxiety that had plagued Ed for 20 years. When he was 17 years old, some friends persuaded Ed to try smoking marijuana. They told him that it would make him feel high—relaxed, sociable, and perhaps a bit giddy. Unfortunately, Ed didn’t react to the drug in the same way that the others had. The physical effects seemed to be the same, but his psychological reaction was entirely different. After sharing two joints with his friends, Ed began to feel light- headed. Then things around him began to seem unreal, as though he were watching himself and his friends in a movie. The intensity of these feelings escalated rapidly, and panic took over. Fright- ening thoughts raced through his head. Was he losing his mind? When would it stop? This experience lasted about two hours.

The marijuana incident had an immediate and lasting impact. Ed became preoccupied with a fear of accidentally ingesting any kind of mind-altering drug, especially LSD. Every spot on his skin

Symptoms of OCD Obsessions are repetitive, unwanted, intrusive cognitive events that may take the form of thoughts or images or urges. They intrude suddenly into consciousness and lead to an increase in subjective anxiety. Obsessive thinking can be distinguished from worry in two primary ways: (1) Obsessions are usually experi- enced by the person as being nonsensical, whereas worries are often triggered by problems in everyday living; and (2) the con- tent of obsessions most often involves themes that are perceived as being socially unacceptable or horrific, such as sex, violence, and disease/contamination, whereas the content of worries tends to center around more acceptable, commonplace concerns, such as money and work (de Silva & Rachman, 2004). Watch the Video Dave: Obsessive Compulsive Disorder (OCD) on MyPsychLab

Compulsions are repetitive behaviors or mental acts that are used to reduce anxiety. Examples include checking many times to be sure that a door is locked or repeating a silent prayer over and over again. These actions are typically considered by the person who performs them to be senseless or irrational. The person attempts to resist performing the compulsion but cannot. The following case study illustrates many of the most common features of obsessions and compulsions.

Ed’s Obsessive-Compulsive Disorder Ed, a 38-year-old lawyer, lived with his wife, Phyllis. Most aspects of Ed’s life were going well, except for the anxiety- provoking thoughts that lurked beneath his relatively easygoing exterior. One focus of Ed’s anxiety was handwriting. He became so tense that his eyes hurt whenever he was forced to write. Feeling exhausted and overwhelmed, Ed avoided writing when- ever possible. The problem seemed utterly ridiculous to him, but he couldn’t rid himself of his obsessive thoughts.

Sinister meanings had somehow become linked in Ed’s imag- ination to the way in which letters and numbers were formed. The worst letters were P and T (the first letters in “Phyllis” and in “Tim,” his younger brother’s name). “Improperly” formed letters reminded Ed of violent acts, especially decapitation and strangu- lation. If the parts of a letter, such as the two lines in the letter T, were not connected, an image of a head that was not attached to its body might pop into his mind.

Closed loops reminded him of suffocation, like a person whose throat had been clamped shut. These images were associ- ated with people whose names began with the malformed letter. As a result of these concerns, Ed’s handwriting had become ex- tremely awkward and difficult to read.

These writing problems made it very difficult for Ed to com- plete his work, especially when he was under time pressure. In one particularly upsetting incident, Ed was responsible for com- pleting an important official form that had to be mailed that day. He came to a section in which he needed to write a capital P and became concerned that he hadn’t done it properly. The loop seemed to be closed, which meant that Phyllis might be

Obsessive thoughts about germs and contamination can trigger frequent ritualistic hand washing that can take hours out of the day and lead to serious skin problems

164 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

clinical patients occur more frequently, last longer, and are as- sociated with higher levels of discomfort. Clinical obsessions are also resisted more strongly, and patients report more difficulty dismissing their unwanted thoughts and urges. Someone who experiences clinical obsessions is also prone to interpret them as meaning that he is a terrible person, someone who might actually act on the urge to harm another person. Research evidence sug- gests that intrusive thoughts are relatively common, and clinical obsessions differ from them in degree rather than in nature.

Ed’s constricted style of forming letters and his habitual pat- tern of going back to check and correct his writing illustrate the way in which compulsions are used to reduce anxiety. If he did not engage in these ritualistic behaviors, he would become ex- tremely uncomfortable. His concern about someone being stran- gled or decapitated if the letters were not properly formed was not delusional, because he readily acknowledged that this was a “silly” idea. Nevertheless, he couldn’t shake the obsessive idea that some dreadful event would occur if he was not excruciat- ingly careful about his writing. He felt as though he had to act, even though he knew that his obsessive thought was irrational. This paradox is extremely frustrating to obsessive-compulsive patients, and it is one of the most common and interesting as- pects of the disorder.

Compulsions reduce anxiety, but they do not produce plea- sure. Thus, some behaviors, such as gambling and drug use, that people describe as being “compulsive” are not considered true compulsions according to this definition.

Although some clinicians have argued that compulsive rituals are associated with a complete loss of voluntary control, it is more accurate to view the problem in terms of diminished control. For example, Ed could occasionally manage to resist the urge to write in his compulsive style; the behavior was not totally automatic. But whenever he did not engage in this ritualistic behavior, his subjective level of distress increased dramatically, and within a short period of time he returned to the compulsive writing style.

Two common forms of compulsive behavior are checking and cleaning. The case of Michael, presented in Chapter 4, pro- vides an example of a person with compulsive cleaning rituals. Compulsive cleaning is often associated with an irrational fear of contamination, and in that respect it bears a strong resemblance to certain phobias. There are passive as well as active features of compulsive cleaning. Compulsive cleaners, like Michael, go out of their way to avoid contact with dirt, germs, and other sources of contamination. Then, when they believe that they have come into contact with a source of contamination, they engage in ritualistic cleaning behavior, such as washing their hands, tak- ing showers, cleaning kitchen counters, and so on. These rituals typically involve a large number of repetitions. Some people may wash their hands 50 times a day, taking several minutes to scrub their hands up to the elbow with industrial-strength cleanser. Others take showers that last two or three hours in which they wash each part of their body in a fixed order, needing to repeat the scrubbing motion an exact number of times.

or clothing seemed as though it might be a microscopic quan- tity of this hallucinogen. He felt compelled to clean his hands and clothes repeatedly to avoid contamination. Intellectually, Ed knew that these concerns were silly. How could a tiny spot on his hand be LSD? It didn’t make any sense, but he couldn’t keep the thought out of his mind.

The most horrifying aspect of the drug experience was the sensation of being totally out of control of his actions and emo- tions. The fear of returning to that state haunted Ed. He strug- gled to resist urges that he had never noticed before, such as the temptation to shout obscenities aloud in church. He also began to worry that he might hurt his younger brother. He resisted these urges with all his might. He never acted on them, but they per- vaded his consciousness and absorbed his mental energy.

The thoughts were so persistent and unshakable that Ed be- gan to wonder if he might, in fact, be a pathological killer. Could he be as deranged and evil as Richard Speck, who had brutally murdered eight nurses in a Chicago apartment building in 1966? Ed spent many hours reading articles about Speck and other mass murderers. The number 8 came to have special meaning to him because of the number of Speck’s victims. Over time, Ed’s fears and worries became focused on numbers and letters. The violent images and impulses became a less prominent part of his every- day life, but the writing difficulties escalated proportionately.

Ed’s thoughts about violence and death illustrate the anxiety- provoking nature of obsessions. It is not just the intrusive quality of the thought, but also the unwanted nature of the thought that makes it an obsession. Some scientists and artists, for example, have reported experiencing intrusive thoughts or inspirational ideas that appear in an unexpected, involuntary way, but these thoughts are not unwanted. Obsessions are unwelcome, anxiety- provoking thoughts. They are also nonsensical; they may seem silly or “crazy.” In spite of the recognition that these thoughts do not make sense, the person with full-blown obsessions is unable to ignore or dismiss them.

Examples of typical obsessive thoughts include the following: “Did I kill the old lady?” “Christ was a bastard!” “Am I a sexual pervert?” Examples of obsessive urges include “I might expose my genitals in public,” “I am about to shout obscenities in public,” “I feel I might strangle a child.” Obsessional images might include mutilated corpses, decomposing fetuses, or a family member be- ing involved in a serious car accident. Although obsessive urges are accompanied by a compelling sense of reality, obsessive people seldom act upon these urges.

Most normal people report having had some intrusive, unac- ceptable thoughts or urges that are similar in many ways to those experienced by patients being treated for obsessive-compulsive disorder (Rachman & de Silva, 1978; Salkovskis & Harrison, 1984). These include urges to hurt other people, urges to do something dangerous, and thoughts of accidents or disease. In contrast to these normal experiences, obsessions described by

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 165

thoughts must not be simply excessive worries about real prob- lems. Intrusive thoughts about overdue bills, for example, would not qualify as obsessions. Finally, DSM-5 provides for a specifica- tion of the person’s level of insight regarding beliefs that are as- sociated with OCD symptoms. The condition can be described as being present: (1) with good or fair insight (i.e., understands that the beliefs are either definitely or probably not true); (2) with poor insight (the person thinks that OCD beliefs are probably true); or (3) with absent insight/delusional beliefs (the person is completely convinced that the OCD beliefs are true).

The line of demarcation between compulsive rituals and nor- mal behavior is often difficult to define. How many times should a person wash her hands in a day? How long should a shower last? Is it reasonable to check more than one time to be sure that the door is locked or the alarm clock is set? DSM-5 has established an arbi- trary threshold that holds that rituals become compulsive if they cause marked distress, take more than an hour per day to perform, or interfere with normal occupational and social functioning.

Additional OCD-related disorders are listed in Table 6.1. Hoarding disorder was added to DSM-5 as a new form of mental disorder. In the previous version of the diagnostic manual, hoarding had been listed as one potential symptom of obsessive-compulsive personality disorder (“Unable to discard worn-out or worthless ob- jects even when they have no sentimental value.” See Chapter 9). It has also been considered a subtype of OCD, presumably because the person’s fear of losing important belongings might be viewed as an obsessive thought (increasing anxiety). Distress associated with allowing other people to touch or move these belongings also bears some resemblance to concerns about symmetry and ordering

Compulsive checking frequently represents an attempt to ensure the person’s safety or the safety and health of a friend or family member. The person checks things, such as the stove or the lock on a door, over and over in an attempt to prevent the occurrence of an imagined unpleasant or disastrous event (e.g., an accident, a burglary, or an assault).

The most common forms of obsessions include immoral thoughts, thoughts about being contaminated or being exposed to illness, unwanted sexual and religious thoughts, and thoughts about harming other people. Data regarding these symptoms are presented in Figure 6.3. Participants in the large epidemiologi- cal survey known as the NCS-R were asked to indicate whether they had experienced certain kinds of obsessions (“unpleasant thought, images or impulses”) and compulsions (“repeated be- haviors or mental acts that you felt compelled to do”). In order to be counted as present, the symptoms had to be present most days for at least a period of two weeks. Almost 30 percent of the people reported having experienced either obsessions or compul- sions at some point during their lives, but most of these people did not qualify for a diagnosis of OCD.

Diagnosis of OCD and Related Disorders DSM-5 defines OCD in terms of the presence of either obsessions or compulsions. Most people who meet the criteria for this dis- order actually exhibit both of these symptoms. The person must attempt to ignore, suppress, or neutralize the unwanted thoughts or impulses, and they must be time-consuming (take more than one hour per day) or cause significant subjective distress or social impairment. The diagnostic manual specifies further that these

FIGURE 6.3 Lifetime prevalence of specific types of obsessions and compulsions, and prevalence of OCD diagnosis given presence of specific symptoms. Source: A. M. Ruscio, D. J. Stein, W. T. Chiu, and R. C. Kessler, 2010, “The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication.” Molecular Psychiatry, 15, 53–63.

0.1 0.2 0.3 0.40

Checking compulsion

Hoarding compulsion

Ordering compulsion

Immoral thoughts

Contamination thoughts

Illness thoughts

Sexual/religious thoughts

Harming thoughts

Prevalence of symptom among all adults

Prevalence of OCD among those with each types of symptom

166 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

negative emotions. As a result, living areas in the person’s home become completely cluttered to the point that they are unusable.

The impairment associated with hoarding is obvious and can become extremely disruptive to the person’s life. Congestion caused by accumulating possessions can lead to major safety risks and health hazards. Fire is one obvious danger. In rare, extreme cases, people have been crushed by piles of heavy belongings that crashed after being stacked to the ceiling.

The symptoms of hoarding are, in many important ways, quite different from symptoms of OCD (Frost, Steketee, & Tolin, 2012; Pertusa et al., 2010).

compulsions (Frost, Steketee, & Tolin, 2012). Research studies concerned with hoarding as a distinct form of psychopathology be- gan to appear in the mid 1990s, and interest in this problem has subsequently exploded. In fact, there are at least two popular real- ity TV programs that are devoted exclusively to the description of people who suffer from clinically significant hoarding.

The core element of hoarding disorder, as it is defined in DSM-5, is unrelenting trouble associated with getting rid of personal belongings. In order to meet the criteria for this dis- order, the person must feel a strong need to save these posses- sions. Throwing the items away leads to a sharp increase in strong

TABLE 6.1 Obsessive-Compulsive Related Disorders in DSM-5 All must be associated with subjective distress or social impairment in order for the person to qualify for a diagnosis.

Body Dysmorphic Disorder Preoccupation with perceived defects in personal appearance. The person believes that these flaws are unsightly or abnormal. The perceived defects are not noticeable, or appear to be completely insignificant, to other people.

Hoarding Disorder Persistent difficulties in getting rid of possessions, regardless of their real value. The reluctance to discard property is due to perceived need to save the items, and it results in accumulation of possessions that obstruct active areas of the person’s home.

Trichotillomania (Hair-Pulling Disorder) Recurrent pulling out one’s own hair, in spite of many attempts to decrease or stop this behavior. The hair may be pulled from any area of the body, with the most common sites being scalp, eyebrows, and eyelids.

Excoriation (Skin-Picking) Disorder Persistent picking at one’s own skin, most often on the person’s face, arms, and hands. This picking leads to skin lesions and is not the result of another medical condition, and it is resistant to the person’s frequent attempts to stop the skin picking or decrease its frequency.

People with hoarding disorder save things that most other people would consider worth- less. The accumulated clutter interferes with use of living and work spaces and can become quite dangerous.

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 167

at her face. Eventually, and without warning, she would suddenly become aware of herself standing in front of the mirror again, with her face bleeding openly. At that point, she would become aware of pain from the deep scratches, but her mood in the after- math of an episode was typically calm.

Amber was not aware of any particular feelings or situations that were likely to trigger an episode. In an effort to prevent face scratching, she had tried covering all of the mirrors in her apartment with newspaper, but it didn’t work. She would eventu- ally find herself in front of the mirror bleeding, after pulling off enough of the paper to create a spot large enough to see her face in the mirror. Unable to control the scratching on her own, she sought professional treatment in an effort to break what she considered to be a terrible habit.

Hair-pulling and skin-picking disorders are quite similar in several ways (Snorrason, Belleau, & Woods, 2012). One is that people with these problems often report certain kinds of negative emotional experiences before episodes, ranging from boredom to anxiety, and a subsequent reduction in these feelings after the problem behavior has stopped. This pattern suggests that the pick- ing and pulling behaviors may serve the purpose of regulating neg- ative emotional states. The connection with negative emotions is also less direct, however, than it is in OCD. In OCD, the experi- ence of an obsession (a specific, intrusive thought) leads to a sharp rise in anxiety. The compulsive behavior is specifically designed to reduce that anxiety (e.g., cleaning compulsions following contam- ination or illness thoughts). Skin-picking and hair-pulling seem to regulate negative emotional states, but they are not specifically triggered by intrusive, unwanted thoughts and impulses.

Another distinction between OCD and these other disorders involves the automaticity of the behavior (Snorrason et al., 2012). A substantial percentage of people with skin-picking and hair- pulling also describe themselves as being in a trance-like state (or feeling hypnotized) while they are engaging in the problem be- havior. Many patients report that they are not aware of the pick- ing or pulling when they are doing it. Patients with OCD, on the other hand, are typically acutely aware of what they are doing when they engage in compulsive rituals.

Course and Outcome of OCD The long-term course of obsessive-compulsive disorder typically follows a pattern of improvement mixed with some persistent symptoms. One remarkable study has reported outcome informa- tion for a sample of 144 patients with severe OCD who were as- sessed at two follow-up intervals: first about five years after they were initially treated at a psychiatric hospital and then again more than 40 years later (Skoog & Skoog, 1999). The data are interesting both because of the very long follow-up interval and because the patients were initially treated between 1947 and 1953, well before the introduction of modern pharmacological and psychological

1. Unlike obsessions, thoughts associated with hoarding are not necessarily intrusive or unwanted. People who engage in hoarding find it pleasant to think about their possessions.

2. The distress associated with hoarding follows as a result of con- gestion of the person’s home (including problems with relatives and sometimes authorities who object to the mess) rather than thoughts about possessions or hoarding behaviors themselves.

3. The experience of obsessions leads to an increase in anxiety, but hoarding behaviors are associated with positive emotion. Anxiety is increased when the person is forced to get rid of the possessions.

In fact, a substantial proportion of people who meet the DSM-5 criteria for hoarding disorder do not qualify for a diagnosis of OCD (Hall et al., 2013). For all of these reasons, it does make sense to consider hoarding as a distinct form of mental disorder.

Trichotillomania is defined in terms of recurrent hair-pulling. People who meet the criteria for this disorder pull out their own hair and, as a result, experience serious hair loss (Duke et al., 2010). The hair is usually pulled from the scalp, eyebrows, or eyelids, but it can be from any area of the body. As in the case of compulsive behaviors, the person attempts unsuccessfully to resist or stop the hair pulling. The extent of hair loss varies in extent and visibility from one person to the next. Some people with this disorder conceal the loss of hair by wearing wigs, hats, or scarves.

Excoriation disorder is defined by repeated skin picking which produces skin lesions. As with other disorders related to OCD, these recurrent skin picking behaviors are resisted unsuccessfully. Most people with this disorder pick at skin on the face, arms, or hands. The following brief case study describes the experience of one young woman who was treated by one of the authors.

Amber’s Skin-picking Amber was a 24-year-old graduate student when she came to the clinic, seeking help to stop herself from scratching at her face with her fingernails. She was a strikingly attractive woman, but her face was covered with rough scars, which looked as though they might have been vestiges of serious acne. For the past three or four years, she had experienced intermittent episodes of scratch- ing that would last anywhere from a few minutes to more than two hours. Sometimes these episodes happened two or three times a week, with the longest interval between episodes being one month. Amber was usually standing in front of a mirror in her bathroom when she started to scratch her face. It often started when she noticed a small blemish or other irregularity on her face. She would lean closer to the mirror and begin to press or pick at the spot with a fingernail. As she ran her finger across her face, she would gradually “zone out” or begin to lapse into what might be called an “out of body experience,” otherwise known as disso- ciation (see Chapter 7). Her thoughts typically wandered to many other topics, and she was usually not at all aware of what she was doing. During the episode, she scratched and poked and picked

168 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

men and women (Timpano et al., 2011). Excoriation disorder appears to be much more common than trichotillomania, though there is some overlap between these disorders (Hayes, Storch, & Berlanga, 2009). The current prevalence of body dysmorphic dis- order is approximately 2 percent (Buhlmann et al., 2010).

Causes of OCD The cognitive model of worry or anxious apprehension places primary emphasis on the role of attentional processes. Worrying is unproductive and self-defeating in large part because it is asso- ciated with a focus on self-evaluation (fear of failure) and negative emotional responses rather than on external aspects of the prob- lem and active coping behaviors. We may be consciously aware of these processes and simultaneously be unable to inhibit them. The struggle to control our thoughts often leads to a process known as thought suppression, an active attempt to stop thinking about something.

It seems simple to say, “Stop worrying,” but it is virtually impossible for some people to do so. In fact, recent evidence sug- gests that trying to rid one’s mind of a distressing or unwanted thought can have the unintended effect of making the thought more intrusive (Wegner, 1994). Thought suppression might actu- ally increase, rather than decrease, the strong emotions associated with those thoughts. The bond between a thought and its associ- ated emotion allows activation of one to result in the reinstate- ment of the other, a kind of dual pathway.

Obsessive-compulsive disorder may be related, in part, to the maladaptive consequences of attempts to suppress unwanted or threatening thoughts that the person has learned to see as being dangerous or forbidden (Abramowitz, Tolin, & Street, 2001; Purdon, 2004). Remember that obsessive thoughts are a common experience in the general population. They resemble “abnormal” obsessions in form and content. However, the ob- sessions of those in treatment for OCD are more intense and, perhaps most importantly, are more often strongly resisted and more difficult to dismiss. This resistance may be a key compo- nent in the association between emotional sensitivity and the development of troublesome obsessive thoughts. People who are vulnerable to the development of OCD apparently react strongly to events that trigger an emotional response. These individuals become aware of their exaggerated reactivity and find it unpleas- ant. In an effort to control their reaction, they attempt to resist or suppress the emotion (Campbell-Sills et al., 2006).

As a result of an individual’s attempt to suppress strong emo- tion, a rebound effect may occur, culminating in a vicious cycle. Thoughts that are present during the instigation of such a cycle become robustly associated with the emotion and may become the content of an obsessive thought. This model may help to ex- plain the episodic nature of obsessive-compulsive symptoms; re- lapse may be triggered by intense emotional episodes.

There are also biological perspectives regarding causal mech- anisms associated with OCD. Some are based on the broad

treatments for the disorder. Slightly less than 30 percent of the patients were rated as being recovered at the first follow-up inter- val. By the time of the 40-year follow-up, almost 50 percent of the patients were considered to show either full recovery or recovery with subclinical symptoms. More than 80 percent of the patients showed improved levels of functioning if we also count people who continued to exhibit some clinical symptoms. Nevertheless, half of the patients in this sample exhibited symptoms of OCD for more than 30 years. This study shows that although many patients do improve, OCD is a chronic disorder for many people.

Much less information is available regarding the course and outcome of the OCD-related disorders. Most evidence suggests that hoarding tends to be a long-term, chronic condition (Tolin et al., 2010). Skin-picking and trichotillomania also seem to be chronic problems that following a waxing and waning course over time (Snorrason et al., 2012).

Frequency of OCD and Related Disorders Approximately two percent of the U.S. population meets diag- nostic criteria for OCD at some point during their lives, and the 12-month prevalence rate for OCD is 1.2 percent (Ruscio et al., 2010). Similar rates have been reported in other countries (Subramaniam et al., 2012). All of the evidence suggests that OCD is less common than most of the anxiety disorders and ma- jor depression. Also unlike the anxiety and depressive disorders, OCD does not appear to show a significant gender difference; men and women are equally likely to be affected (Adam et al., 2012; Torres et al., 2006).

The 12-month prevalence of other OCD-related disorders is illustrated in Figure 6.4. These data should be considered tenta- tive because none of these disorders has been included in large- scale epidemiological studies using structured interviews and DSM-5 criteria. Nevertheless, it does seem clear that hoarding disorder and excoriation (skin-picking) disorder are both more common than the other kinds of problems. Hoarding disorder is much more common than OCD, affecting almost 6 percent of community residents, with no differences in frequency between

FIGURE 6.4 12-month prevalence of OCD and OCD-related disorders.

0.06

P er

ce nt

0.01

0

0.02

0.03

0.04

0.05

OCD BDD

BDD: Body Dysmorphic Disorder ED: Excoriation (Skin-picking) Disorder

EDTrichotillomaniaHoarding disorder

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 169

patients and the ideas that they generate. New hypotheses will need to be evaluated using rigorous research methods (see Critical Thinking Matters).

Treatment of OCD A variety of psychological and biological forms of treatment have been shown to be effective with people suffering from OCD. We begin our discussion of this literature by describing proce- dures that were used in an effort to help Ed, the person with obsessive-compulsive disorder whose problems were described at the beginning of this section of the chapter.

Ed’s Treatment Ed’s psychiatrist gave him a prescription for clomipramine (Anafranil), an antidepressant drug that is also used to treat

foundation of research regarding attention and emotion regula- tion. The neurological foundations of OCD seem to involve re- gions of the brain that are different than those involved in other types of anxiety disorders (Bartz & Hollander, 2006). As we dis- cussed in Chapter 4, obsessions and compulsions are associated with multiple brain regions, including the basal ganglia (a system that includes the caudate nucleus and the putamen), the orbital prefrontal cortex, and the anterior cingulate cortex (see Figure 4.2 on page 101). These circuits are overly active in people with OCD, especially when the person is confronted with stimuli that provoke his or her obsessions (Husted et al., 2006; Menzies et al., 2008).

By moving OCD to its own chapter, the authors of DSM-5 will probably draw even more research attention to this serious mental disorder. Studies aimed at understanding the origins of OCD will continue to be inspired by observations of clinical

CRITICAL THINKING matters

Can a Strep Infection Trigger OCD in Children?

New hypotheses about the causes of mental disorders are usually based on clinical observations. These ideas are then evaluated in research studies designed to test their validity. Sometimes the data support the new idea, and sometimes they don’t. During this period of evaluation, clinicians and scientists find themselves in a period of uncertainty, with some people embracing what they consider to be an important advance in knowledge while others provide skeptical criticism. Both groups need to think critically about relevant evidence.

This state of affairs is currently illustrated by a controversial proposal regarding the development of OCD in children. Clinical scientists at the National Institute of Mental Health suggested that, in some cases, symptoms of OCD develop suddenly following a strep infec- tion. According to their hypothesis, antibodies that are triggered by the infection attack nerve cells in the basal ganglia of the brain (see Figure 4.1 on page 86). The investigators created a new term to use in diagnosing children with OCD who have a sudden onset and also test positive for a strep infection. They call the disorder pediatric au- toimmune neuropsychiatric disorders associated with streptococcal infection, or PANDAS (Swedo & Grant, 2005). They recommend that a throat culture be given to any child who shows a sudden onset of symptoms of OCD. Children who test positive for strep are put on long-term antibiotics that are claimed, in some cases, to produce “miraculous results” (Anderson, 1996).

Does the recognition of PANDAS represent a breakthrough discov- ery? Is it a valid diagnostic concept? Or is it a mistaken hypothesis with potentially risky treatment implications? Reasonable people have taken both sides. The empirical evidence is incomplete (da Rocha, Correa, & Teixeira, 2008; Leckman et al., 2011), and some say it is weak (Gilbert & Kurlan, 2009). Many cases have been

described that fit this clinical profile. One paper described 109 cases in which the parents described a rapid onset of OCD symptoms (Swedo et al., 1998). Among these, 50 tested positive for strep. That leaves 59 rapid-onset cases that must have been triggered by some other, unknown factor. But even in the cases that did test positive, the existence of a strep infection does not prove that it was causally related to the OCD.

If 100 kids fall out of a tree and break their arms and we test them for strep, there’s going to be a very high per- centage of children who have evidence of recent infection. That doesn’t mean strep is the reason they fell out of a tree. (Shulman, quoted in Belkin, 2005)

Skeptics argue that, until more conclusive evidence is available to support the theory, we should assume that children who experi- ence obsessions and compulsions are suffering from OCD, nothing more or less (Kurlan & Kaplan, 2004). Undue emphasis on the use of antibiotic treatment may lead parents to ignore more conventional treatments for the disorder. In fact, the combination of cognitive be- havior therapy and SSRI medications has been shown to be effective for children with PANDAS-related OCD (Storch et al., 2006). Clini- cians should also consider potential problems associated with the use of antibiotics as a form of treatment for children with OCD. Risks include the possibility of developing drug allergies and the promo- tion of antibiotic resistance.

While PANDAS is an intriguing hypothesis, remember that the bur- den of proof lies with those who propose new diagnostic categories or causal theories. Until it has been supported by strong empirical evidence, which is not yet the case with regard to PANDAS, the community of scientists assumes that the new hypothesis is false.

170 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

compulsive response (Abramowitz, 2006; Franklin & Foa, 2002). Neither component is effective by itself. The combination of ex- posure and response prevention is necessary because of the way in which people with obsessive-compulsive disorder use their com- pulsive rituals to reduce anxiety that is typically stimulated by the sudden appearance of an obsession. If the compulsive behavior is performed, exposure is effectively cut short.

Consider, for example, the treatment program employed with Ed. His obsessive thoughts and images, which centered around violence, were associated with handwriting. They were likely to pop into his mind when he noticed letters that were poorly formed. In an effort to control these thoughts, Ed wrote very carefully, and he corrected any letter that seemed a bit ir- regular. By the time he entered behavior therapy, Ed had avoided writing altogether for several months. The therapist arranged for him to begin writing short essays on a daily basis to be sure that he was exposed, for at least 30 minutes each day, to the situation that was most anxiety-provoking. He encouraged Ed to deliber- ately write letters that did not conform to his compulsive style. In their sessions, for example, Ed was also required to write long sequences of the letter T in which he deliberately failed to con- nect the two lines. He was not allowed to go back and correct this “mistake.” The combination represents prolonged exposure to an anxiety-provoking stimulus and response prevention.

Controlled outcome studies indicate that this approach is ef- fective with most OCD patients (Allen, 2006). After a few weeks of treatment with exposure and response prevention, most pa- tients show improvements that are clinically important. On the other hand, some patients (perhaps as many as 20 percent) do not respond positively to this form of treatment and many continue to exhibit mild symptoms of the disorder after they have been successfully treated.

BIOLOGICAL TREATMENTS Medication is also beneficial for many patients with OCD. Selective serotonin reuptake inhibitors are used most frequently. Specific SSRIs used with OCD patients include fluoxetine (Prozac), fluvoxamine (Luvox), and sertraline (Zoloft). Controlled studies indicate that these drugs can be quite effective in the treatment of OCD (Dell’Osso et al., 2006). The SSRIs are often preferred to other forms of medication because they have fewer side effects.

Clomipramine (Anafranil), another tricyclic antidepressant, has been used extensively in treating obsessive-compulsive disor- der. Several placebo-controlled studies have shown clomipramine to be effective in treating OCD (Abramowitz, 1997; Kozak, Li- ebowitz, & Foa, 2000). One study found that more than 50 per- cent of the patients who received clomipramine improved to a level of normal functioning over a period of 10 weeks, compared to only 5 percent of the patients in a placebo group (Katz, De- Veaugh-Geiss, & Landau, 1990). Patients who continue to take the drug maintain the improvement, but relapse is common if medication is discontinued.

people with severe obsessions. Weekly psychotherapy sessions continued as the dose was gradually increased. The medication had a beneficial impact after four weeks. Ed said that he had be- gun to feel as though he was trapped at the bottom of a well. After the medication, he no longer felt buried. His situation still wasn’t great, but it no longer seemed hopeless or unbearable. He was also less intensely preoccupied by his obsessive violent im- ages. They were still there, but they weren’t as pressing. The drug had several annoying, though tolerable, side effects. His mouth felt dry, and he was occasionally a bit dizzy. He also noticed that he became tired more easily. Although Ed was no longer feel- ing seriously depressed, and the intensity of his obsessions was diminished, they had not disappeared, and he was now avoiding writing altogether.

Because the obsessions were still a problem, Ed’s psychiatrist referred him to a psychologist who specialized in behavior ther- apy for anxiety disorders. He continued seeing the psychiatrist every other week for checks on his medication, which he contin- ued to take. The new therapist told Ed that his fears of particular letters and numbers would be maintained as long as he avoided writing. Ed agreed to begin writing short essays every day, for a period of at least 30 minutes. The content could vary from day to day—anything that Ed felt like writing about—but he was encour- aged to include the names of his wife and brother as often as possible. Furthermore, he was instructed to avoid his compulsive writing style, intentionally allowing the parts of letters to be sepa- rated or loops to be closed. At the beginning and end of each essay, Ed was required to record his anxiety level so that the ther- apist could monitor changes in his subjective discomfort. Over a period of 8 to 10 weeks, Ed’s handwriting began to change. It was less of a struggle to get himself to write, and his handwriting became more legible.

The final aspect of behavioral treatment was concerned with his fear of axes. Ed and his therapist drew up a list of objects and situations related to axes, arranging them from those that were the least anxiety-provoking through those that were most frightening. They began with the least frightening. In their first exposure session, Ed agreed to meet with the psychologist while a relatively dull, wood-splitting maul was located in the adjoin- ing room. Ed was initially quite anxious and distracted, but his anxiety diminished considerably before the end of their two- hour meeting. Once that had been accomplished, the therapist helped him to confront progressively more difficult situations. These sessions were challenging and uncomfortable for Ed, but they allowed him to master his fears in an orderly fashion. By the end of the twelfth session of exposure, he was able to hold a sharp ax without fear.

EXPOSURE AND RESPONSE PREVENTION The most effec- tive form of psychological treatment for obsessive-compulsive disorder combines prolonged exposure to the situation that in- creases the person’s anxiety with prevention of the person’s typical

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 171

getting HELP

Most people suffering from anxiety disorders can be treated successfully. Several forms of intervention are beneficial, primarily behavior therapy, cognitive therapy, and medication. If you plan to work with a professional therapist, do some research before you begin working with a specific service provider. Read about treatments that have been evaluated empirically. One terrific source of information is a Web site on research-supported psychological treatments that is maintained by the Society of Clinical Psychology. The address is: www.psychologicaltreatment.org.

Some other excellent Internet sites may help you find the best therapist for you, hopefully someone who uses one of the procedures that has been shown to be effective. Patient-run organizations have established support groups in many com- munities and share information about treatment alternatives. One outstanding example is the Anxiety Disorders Association of America. The URL for its website is www.adaa.org. It includes a consumer’s guide to treatment alternatives that is organized by specific types of anxiety disorders. More detailed informa- tion about obsessive-compulsive disorder and related problems can be obtained from the Obsessive Compulsive Foundation, a

not-for-profit organization composed of people with OCD, their families, and professionals. Its Web address is www .ocfoundation.org.

Some people may be able to make improvements on their own with the advice of a useful self-help book. There are a lot of good alternatives to choose from in the area of anxiety disor- ders. We recommend two books that describe a combination of cognitive and behavioral approaches to treatment. Triumph over Fear, by Jerilyn Ross and Rosalynn Carter, describes the successful experiences of people who have recovered from vari- ous types of anxiety disorders, including phobias, panic disorder, and generalized anxiety disorder. Practical, self-help strategies are also summarized in Overcoming Panic, Anxiety, and Phobias: New Strategies to Free Yourself from Worry and Fear, written by Shirley Babior and Carol Goldman. This book includes simple in- structions in progressive muscle relaxation, cognitive techniques to master anxiety, and exposure procedures for overcoming avoidance. Finally, more specific information about dealing with obsessive-compulsive disorder can be found in Stop Obsessing: How to Overcome Your Obsessions and Compulsions, by Edna Foa and Reid Wilson.

Anxiety disorders are defined in terms of a preoccupation with, or persistent avoidance of, thoughts or situations that provoke fear or anxiety. Anxiety involves a diffuse emo- tional reaction that is associated with the anticipation of future problems and is out of proportion to threats from the environment.

A panic attack is a sudden, overwhelming experience of terror or fright. Panic attacks are defined largely in terms of a list of somatic sensations, ranging from heart palpitations, sweating, and trembling to nausea, dizziness, and chills.

Phobias are persistent and irrational narrowly defined fears that are associated with avoidance of a specific object or situation. The most complex type of phobic disorder is agoraphobia, which is usually described as fear of public spaces.

DSM-5 recognizes several specific subtypes of anxiety disorders: panic disorder, specific phobia, social anxiety, agoraphobia, and generalized anxiety disorder.

Anxiety disorders are the most common type of mental disorder. Specific phobias have a one-year prevalence of about 9 percent among adults, followed by social anxiety disorder (7 percent), generalized anxiety disorder (3 percent), and panic disorder (3 percent).

Severe life events, particularly those involving danger, insecurity, or family conflict, can lead to the development of anxiety symp- toms. Various kinds of childhood adversity, including parental neglect and abuse, increase a person’s risk for the later onset of an anxiety disorder.

The learning model explained the development of phobic disor- ders in terms of classical conditioning. A modified learning view, known as the preparedness model, is based on recognition that there are biological constraints in this process. We may be pre- pared to develop intense, persistent fears only to a select set of objects or situations.

Cognitive theorists have argued that panic disorder is caused by the catastrophic misinterpretation of bodily sensations or per- ceived threat.

Summary6

172 CHAPTER 6 anxiety disorders and obsessive-compulsive disorder

People who are prone to excessive worrying are unusually sensi- tive to cues that signal the existence of future threats. The recog- nition of danger cues triggers a maladaptive, self-perpetuating cycle of cognitive processes that can quickly spin out of control.

Twin studies indicate that genetic factors are involved in the etiology of several types of anxiety disorders, including panic disorder, generalized anxiety disorder, and social anxiety disorder. The influence of environmental events seems to be greatest in specific phobias.

Studies of fear conditioning in animals have identified specific pathways in the brain that are responsible for detecting and organizing a response to danger. The amygdala plays a central role in these circuits. Several other areas of the brain are also associated with anxiety and the symptoms of anxiety disorders.

Serotonin, norepinephrine, GABA, and dopamine are some of the neurotransmitters that are involved in the production

of panic attacks. Many interacting neurotransmitter systems play a role in the etiology of anxiety disorders, and they are largely the same ones that are also involved in major depression.

Several psychological approaches to the treatment of anxiety disorders have been shown to be effective. These include the use of exposure and flooding in the treatment of phobic dis- orders, prolonged exposure and response prevention in the treatment of obsessive-compulsive disorders, and cognitive therapy in the treatment of panic disorder and GAD. Various types of medication are also effective treatments for anxiety disorders.

Obsessions are repetitive, unwanted, intrusive cognitive events that may take the form of thoughts or images or urges. They intrude suddenly into consciousness and lead to an increase in subjective anxiety. Compulsions are repetitive behaviors that reduce the anxiety associated with obsessions.

6.1 Why is a panic attack sometimes calleda “false alarm?” Panic attacks resemble normal fear responses, but they are triggered at an inappropriate time (when the person is not confronted by an immediate source of danger) . . . (see page 147).

6.2 What is the expected long-term outcome for people with anxiety disorders? Some people recover, but they are most often chronic conditions . . . (see page 151).

6.3 Is there a unique causal pathway for each type of anxiety disorder? Probably not. Studies of environmental events, genetic factors, and neurobiological mechanisms suggest that pathways leading to different types of anxiety disorders overlap to a considerable extent . . . (see page 153).

6.4 If phobias are learned quickly and easily, why are they so hard to extinguish? Because their development is guided by a “prepared module,” which is presumably efficient, highly selective, and operating outside con- scious awareness . . . (see page 154).

6.5 Do psychological treatments have any advantages over medication for treatment of anxiety? Yes. Problems with medication include various side effects, the po- tential for addiction (benzodiazepines), and increased risk of relapse following their discontinuation . . . (see page 162).

6.6 What is the difference between obsessions and normal intrusive thoughts? Their content is similar (such as impulses to hurt other people). The differences hinge on duration, frequency, and the extent to which the person struggles against the obsessive thought . . . (see page 164).

6.7 Why is response prevention coupled with exposure in the treatment of OCD? If the therapist did not prevent compulsive behaviors, a patient with OCD would use them to reduce anxiety that is stimulated by exposure to the obsession and the process would not be effective . . . (see page 170).

critical thinking review

The Big Picture

key terms agoraphobia 148 anxiety 146 compulsions 163 fear 146

generalized anxiety disorder (GAD) 150

obsessions 163 panic attack 147

panic disorder 150 phobias 147 preparedness model 154 social anxiety disorder 148

specific phobia 148 worry 146

anxiety disorders and obsessive-compulsive disorder CHAPTER 6 173

Virtual Case Studies

Virtual Case Studies offers you a science-based, interactive simulation where you can learn how a number of risk factors and protective factors could impact disorder development in a virtual person. As you progress through the simulation you will not act as the character or as a clinician, but will be able to independently explore a variety of different behaviors, events, and outcomes that one who suffers from a disorder could potentially encounter. You can access the Virtual Case Study on Anxiety Disorders at mypsychlab.com.

FPO

acute and posttraumatic stress disorders, dissociative disorders, and somatic

symptom disorders

7

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 175

7 The Big Picture learning objectives

7.1 How does DSM-5 define trauma?

7.2 Does trauma always lead to PTSD?

7.3 Can the unconscious mind cause mental disorders?

7.4 What are recovered memories?

7.5 Is multiple personality disorder real?

7.6 Were conversion disorders common in Freud’s time?

A soldier experiences a flashback and prepares for combat—as a ci- vilian at home. A young woman’s personality transforms completely, almost as if an alien has taken control of her body. A middle-aged man claims his leg is paralyzed with weakness, yet neurological tests show normal strength. To the extent they can be believed, each example involves the dramatic transformation of stress or trauma into strange psychological symptoms. Such unusual problems defy ready expla- nation and raise profound questions about the nature and power of unconscious mental processes, information processing outside of con- scious awareness. Can the unconscious mind really affect people in such mysterious ways?

Overview We repeatedly ask this question in this chapter in the context of discussing traumatic stress disorders, dissociative disorders, and somatic symptom disorders. These psychological prob- lems look very different, but they share an important similarity: dissociation—the disruption of the normally integrated mental processes involved in memory, consciousness, identity, or percep- tion. You should know from the outset that we are entering con- troversial territory in this chapter. Some psychologists view the unconscious mind as all-powerful. Others doubt its existence. We approach the topic with both skepticism and curiosity. Especially

given limited research, we are skeptical about problems that can be overdramatized. At the same time, we are captivated by un- usual case studies that raise fascinating questions about their origin—and about how the mind works. We begin by considering the least controversial and most studied problem, traumatic stress disorders.

Acute and Posttraumatic Stress Disorders Stress is an inevitable, and in many ways a desirable, part of ev- eryday life. Some stressors, however, are so catastrophic and hor- rifying that they can cause serious psychological harm. Traumatic stress is defined in DSM-5 as an event that involves actual or threatened death, serious injury, or sexual violence to self, or witnessing others experience trauma, learning that loved ones have been traumatized, or repeatedly being exposed to details of trauma. Trauma includes rape, military combat, bombings, air- plane crashes, earthquakes, major fires, and devastating automo- bile wrecks. In recent years, we know trauma all too well as a result of the September 11, 2001 terrorist attacks, sexual assaults, combat in Iraq and Afghanistan, and school shootings like the dreadful massacre at Sandy Hook Elementary School.

It is normal for survivors, witnesses, and loved ones to be greatly distressed by trauma. For some, however, the disturbance continues long after the trauma has ended. Acute stress disor- der (ASD) occurs within a month after exposure to traumatic stress. Posttraumatic stress disorder (PTSD) lasts longer than one month and sometimes has a delayed onset. Although DSM-5 describes them somewhat differently, both ASD and PTSD in- volve essentially the same symptoms: intrusive reexperiencing of the event, avoidance of reminders of the trauma, negative mood or thoughts, exaggerated arousal or reactivity, and often, dissocia- tion. The following case study describes the enduring trauma of sexual assault.

An impromptu memorial for victims of the Sandy Hook School shootings.

176 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

Stephanie found it painful but also helpful to talk about her as- sault with friends and, over time, more publicly. After the passing of the one-year anniversary, she actually began to lecture about her experiences to classes and to women’s groups. Lecturing gave her some relief, and more importantly, it gave her a sense that some good might come from her trauma. Stephanie also testified at the trial of her assailant, who was convicted and sent to prison for 20 years. Although she appeared strong in the courtroom, the trial renewed many of Stephanie’s symptoms. She again relived the terror of the assault, avoided being alone at night, and be- came fearful and hypervigilant about dangers in her world.

Once her assailant was imprisoned, Stephanie felt a degree of resolution. Still, she could not fully banish the demons. She again experienced intensely distressing episodes near the second and third anniversaries of the assault. Even at other times, Steph- anie could unexpectedly fall victim to terror. For example, more than three years after the assault, her boyfriend (now her hus- band) silently entered her room after returning home unexpect- edly one night. Frightened by his sudden appearance, Stephanie first screamed in terror, then sobbed in uncontrollable fear, and felt numb and unreal for several days afterwards.

Stephanie showed amazing bravery during her assault, throughout the trial, and in her public discussions of her trauma. But despite her strength, Stephanie could not prevent or con- trol the recurrent terror of PTSD brought on by a violent sexual assault.

Symptoms of ASD and PTSD The essential difference between ASD and PTSD is duration. ASD lasts no longer than a month, while PTSD continues or sometimes begins at least a month after the trauma. The symp- toms of ASD and PTSD are basically the same, even though DSM-5 defines them somewhat differently (as you will see and perhaps be confused by). Both problems include (1) intrusive reexperiencing, (2) avoidance of reminders of the trauma, (3) increased arousal or reactivity, (4) negative mood or thoughts, and often (5) dissociation.

InTruSIve reexPerIencIng Survivors often experience intrusive symptoms following trauma, symptoms sometimes called reexperiencing. Some people experience repeated, dis- tressing memories of the incident. Others relive the trauma in horrifying dreams. Many people have repeated and intrusive flashbacks, sudden memories during which the trauma is re- played in images or thoughts—often at full emotional intensity. In rare cases, reexperiencing occurs as a dissociative state, where the person feels and acts as if the trauma actually were recurring in the moment. A combat veteran might act as if he were back in battle, and he may even take dangerous actions like gathering weapons or barricading himself in his residence. Typically, dis- sociative states are of short duration, but in unusual cases they can last for days.

The Enduring Trauma of Sexual Assault One spring evening, Stephanie Cason, a bright, attractive, and well-adjusted 27-year-old graduate student, ran outside to inves- tigate a fire in another building in her apartment complex. While watching the firemen, Stephanie chatted with a man who she as- sumed was a neighbor. After talking with a few other people, she returned to her apartment. The fire had caused a power outage, but Stephanie found her way upstairs and changed into her night- clothes. When she came back downstairs, she was startled by the man she had met outside. Without saying a word, he raised a tire iron and struck Stephanie across the top of her head— repeatedly—until she fell to the floor and stopped screaming. Stephanie was cut deeply and stunned by the vicious blows, but she attempted to resist as the man began to grab at her breasts and rip at her clothes. He began to mutter obscenities and told Stephanie he wanted to have sex with her. Stephanie thought, “He’s going to kill me.”

Somehow Stephanie managed to think clearly despite the blood pouring from her head. She “agreed” to have sex with her assailant but told him that she needed to “freshen up” first. Eventually, he let her go to clean up. When Stepha- nie reached her bedroom, she shoved a bureau in front of the door and screamed frantically out the window for help. Her screams frightened her attacker, who tried to flee. But one of the firefighters tackled and captured him as he attempted to run away.

Stephanie saved herself from being raped, but she could not protect herself from the emotional fallout of her sexual assault. For days, eventually weeks and months, she felt intermittently ter- rified, dazed, and grateful to be alive. She replayed the horror of the evening in her mind repeatedly, and when she managed to fall asleep, she often was awakened by frightening nightmares. Stephanie was terrified to be alone, especially at night, but also at many times during the day. She relied on the unwavering support of her boyfriend and friends to stay nearby and help her cope.

Shortly after the assault, Stephanie sought help from a skilled clinical psychologist, but she fell into a depression despite the therapy. Antidepressant medication helped somewhat with her mood and lethargy, but for months she was hypervigilant— constantly on the lookout for new threats. She had difficulty con- centrating and experienced intermittent feelings of numbness or unreality. In addition, she frequently reexperienced the images and emotions surrounding the dreaded event. She was able to re- sume her studies after about three months, and within six or eight months she was working fairly regularly but with considerably less confidence and concentration than before. As the anniversary of her assault approached, Stephanie grew increasingly upset. The spring weather, usually a welcome change, reminded her of the terror of the previous year. Her feelings of unreality returned. She had more flashbacks, reliving the dreaded night. The nightmares and fears of being alone reappeared. As the dreaded date passed, her reactions eased slowly. After about two or three months, she was able to resume her normal life—as normal as her life could be.

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 177

fear, a nger, or guilt, or feelings of detachment from others. In some cases, there is a general numbing of responsiveness or emo- tional anesthesia, a term that well captures the emotional dampen- ing. Other people’s negativity is more cognitive. They may blame themselves, repeatedly question what they might have done dif- ferently, or see the world in an unrealistically negative way.

DISSocIATIve SymPTomS Though not required for a diagno- sis of either ASD or PTSD, dissociative symptoms are common following trauma. Many people feel dazed, and act “spaced out.” Others experience depersonalization, feeling cut off from them- selves or their environment. They might feel like “a robot,” or as if they were sleepwalking. Others experience derealization, a marked sense of unreality. Immediately after 9/11, many people awoke wondering if the terrorist attacks had been only a nightmare—a sense of unreality that continued for days or longer. Some peo- ple experience dissociative amnesia—they are unable to remember aspects of the trauma events (Harvey, Bryant, & Dang, 1998).

Diagnosis of ASD and PTSD DSM-5 no longer considers ASD and PTSD to be anxiety disor- ders (see Chapter 6) and instead created a new diagnostic group- ing called Trauma- and stressor-related disorders. This new category includes adjustment disorders, difficulties coping with normal challenges in life, which we discuss in Chapter 17, and a few ad- justment problems found among children. In essence, ASD and PTSD are now in their own diagnostic category.

PoSTTrAumATIc STreSS DISorDer Formally, the DSM-5 diagnosis of PTSD requires only four of the symptoms we have discussed, while a subtype is defined by the presence of dissocia- tive symptoms, depersonalization or derealization (see “DSM-5: Criteria for Posttraumatic Stress Disorder” on p. 178). This orga- nization partially reflects controversy about the role of dissociation in PTSD. Some experts have suggested that ASD and PTSD re- ally are dissociative disorders (van der Kolk & McFarlane, 1996). We do not view PTSD as a dissociative disorder, but discuss both problems in this chapter because they raise similar issues about un- conscious mental processes. As you look through the DSM-5 di- agnostic criteria in “DSM-5: Posttraumatic Stress Disorder,” note that dissociation is involved in many PTSD symptoms, not just the explicit dissociative symptoms.

Historically, maladaptive reactions to trauma have been of particular interest to the military, where “normal” performance is expected in the face of the trauma of combat. Military concern ini- tially focused on battle dropout, that is, men who leave the field of action as a result of what has been called shell shock or combat neurosis (Jones, Thomas, & Ironside, 2007). During the Vietnam War, however, battle dropout was less frequent than in earlier wars, but delayed reactions to combat were much more common (Figley, 1978). This prompted much interest in PTSD, a condition first listed in the DSM in 1980. PTSD lasts longer than a month or emerges after that amount of time has passed following a trauma.

AvoIDAnce Persistent avoidance of stimuli associated with the trauma is another symptom of ASD and PTSD. Trauma victims may attempt to avoid thoughts or feelings related to the event, or, like Stephanie, they may avoid people, places, or activities that remind them of the trauma. Avoidance also may include refusal to discuss the events or the feelings resulting from trauma. Avoidance of terrify- ing feelings makes complete sense, especially in the short run. Yet the road to longer term healing often involves facing feelings, memories, and perhaps some of the circumstances surrounding trauma.

IncreASeD ArouSAl or reAcTIvITy People suffering from ASD and PTSD often experience increased arousal following the trauma, a symptom that, when it is more severe, predicts a worse prognosis (Schell, Marshall, Jaycox, 2004). Stephanie’s hypervigi- lance in searching for danger is a classic example of hyperarousal, as was her exaggerated startle response, excessive fear in reaction to the unexpected. ASD and PTSD were previously classified as anxiety disorders because of the hyperarousal symptoms. However, DSM-5 moved the disorders into a new category, in part, because height- ened reactivity can take other forms. Instead of showing increased anxiety, some people become irritable and prone to angry out- bursts. Others have trouble concentrating or sleeping.

negATIve mooD or ThoughTS People may experience a range of negative feelings in ASD and PTSD. These may in- clude the inability to experience positive emotions, persistent

Following trauma, many people have intrusive flashbacks, sudden memories during which the trauma is replayed in images and thoughts often at full emotional intensity.

178 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

criteria for Posttraumatic Stress Disorder DSM-5

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close

family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

note: Criterion A4 does not apply to exposure through elec- tronic media, television, movies, or pictures, unless this expo- sure is work related.

B. Presence of one (or more) of the following intrusion symp- toms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories

of the traumatic event(s).

note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

note: In children, there may be frightening dreams without recognizable content.

3. Dissociative reactions (e.g., flashbacks) in which the individ- ual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)

note: In children, trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

c. Persistent avoidance of stimuli associated with the trau- matic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories,

thoughts, or feelings about or closely associated with the traumatic event(s).

2. Avoidance of or efforts to avoid external reminders (peo- ple, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Inability to remember an important aspect of the traumatic

event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

2. Persistent and exaggerated negative beliefs or expec- tations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).

3. Persistent, distorted cognitions about the cause or conse- quences of the traumatic event(s) that lead the individual to blame himself/herself or others.

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

5. Markedly diminished interest or participation in significant activities.

6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions

(e.g., inability to experience happiness, satisfaction, or loving feelings).

e. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no

provocation) typically expressed as verbal or physical aggression toward people or objects.

2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep

or restless sleep).

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

g. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

h. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association.

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 179

AcuTe STreSS DISorDer Except that ASD lasts for less than a month, the diagnostic criteria for ASD and PTSD are the same conceptually. Frustratingly, however, the details of the DSM-5 di- agnostic criteria differ somewhat for ASD (see “DSM-5: Acute Stress Disorder”). We know of no good empirical or conceptual reason for this. The DSM-5 does not explain why the required

symptoms differ, why symptoms are expected to change a month and a day following trauma, or how many people who meet diag- nostic criteria for the nine required symptoms of ASD also meet criteria for the six required symptoms of PTSD (see “DSM-5: Posttraumatic Stress Disorder” and “DSM-5: Acute Stress Disorder”).

criteria for Acute Stress Disorder DSM-5 A. Exposure to actual or threatened death, serious

injury, or sexual violation in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to

others. 3. Learning that the event(s) occurred to a close family mem-

ber or close friend. note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders col- lecting human remains, police officers repeatedly exposed to details of child abuse).

note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this expo- sure is work related.

B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dis- sociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:

Intrusion Symptoms

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/ or affect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recog- nizable content.

3. Dissociative reactions (e.g., flashbacks) in which the individ- ual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur in a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) note: In children, trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic events(s).

negative mood

5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

Dissociative Symptoms

6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing).

7. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

Avoidance Symptoms

8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Arousal Symptoms

10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).

11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.

12. Hypervigilance. 13. Problems with concentration. 14. Exaggerated startle response.

c. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.

note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

e. The disturbance is not attributable to the physiologi- cal effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association.

180 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

about violence to a loved one, or repeated, extreme exposure, for example, first responders collecting human remains.

Any trauma is horrific, but different events have unique psychological consequences. Thus, researchers study both common and unique reactions to traumatic events including com- bat ( Monson et al., 2006), terrorism (Hobfoll, Canetli-Nisim, & Johnson, 2006), child sexual abuse (McDonagh et al., 2005), spouse abuse (Taft et al., 2005), children’s coping with residential fires (Jones & Ollendick, 2002), and torture (Basoglu et al., 1997). We discuss some unique aspects of sexual assault in The Trauma of Sexual Assault box.

One trauma of particular concern is exposure to disasters, which commonly involve large numbers of people. A random telephone survey of 1,008 residents living south of 110th Street in Manhattan on September 11, 2001, found that, regardless of whether they directly witnessed the World Trade Center (WTC) attacks, 7.5 percent—67,000 people—suffered from PTSD one month later (Galea et al., 2002). This obviously is a huge pub- lic health issue, yet there are reasons for optimism, too. Four months after the attacks, the prevalence of PTSD in the same area dropped to 1.7 and to 0.6 percent after six months (Galea et al., 2003). What protected the New Yorkers? We cannot know for certain, but key influences surely include the outpouring of support (McNally, Bryant, & Ehlers, 2003) and underestimated human resilience (Bonanno, Westphal, & Mancini, 2011).

Firefighters, police, and paramedics must remain calm during a disaster, but this does not make them immune to

These discrepancies are surprising as well as frustrating, be- cause ASD was added to the DSM (in 1994) in the hope that early intervention would prevent the development of PTSD (Frances et al., 1995). In fact, the presence of ASD symptoms predicts PTSD better than the full diagnosis (Bryant et al., 2010). Interventions with ASD do reduce the number of expected cases of PTSD (Bryant et al., 2010).

Some experts wonder whether ASD really describes normal reac- tions to trauma and suggest that the reaction should not be called a mental disorder (Bryant et al., 2010). Many experts raise similar ques- tions about PTSD, a diagnosis that may be handed out too easily, particularly to combat veterans returning from Iraq and Afghanistan. Many normal reactions to combat and to readjustment to civilian life are being called PTSD, in part because mental health resources and veterans’ benefits are tied to the diagnosis (Dobbs, 2009).

WhAT DeFIneS TrAumA DSM-5 defines trauma as an expo- sure to actual or threatened death, serious injury, or sexual viola- tion either (1) directly, (2) as a witness, (3) learning of violence to a loved one, or (4) through repeated exposure to details of trauma. Sexual violation is a new part of the definition, reflecting both the frequency and the intensity of this trauma, especially for women. The definition of exposure also is more explicit. This is a result of controversy about whether PTSD can be caused by indirect expo- sure, such as seeing horrible scenes of 9/11 on television (Neria & Galea, 2007). Media exposure does not qualify as traumatic stress (Bryant et al., 2010). Secondary exposure is limited to learning

The Trauma of Sexual Assault

Like many other traumas, sexual assault is all too common. Almost 10 percent of women report having been raped at least once in their lifetime, according to national surveys, and 12 percent report having been sexually molested (Kessler et al., 1995). Other evidence suggests a notably higher prevalence when the data include acquaintance rapes, assaults committed by people known to the victim (Goodman, Koss, & Russo, 1993).

Rape can be devastating physically, socially, and emotionally. Thirty-nine percent of rape victims are physically injured on parts of their bodies other than the genitals. A significant proportion of rape victims are infected with sexually transmitted diseases, and about 5 percent of rapes result in pregnancy (Goodman et al., 1993). Socially, sexual assault can undermine women’s work, as well as their intimate relationships (Byrne et al., 1999).

Most victims of sexual assault show the symptoms of PTSD. Victims may reexperience the horrors of the assault; they may feel numbed in reacting to others, particularly sexual partners; they may avoid any potentially threatening situa- tion; and they may maintain both autonomic hyperarousal and

hypervigilance against possible victimization. Depression is also common. Sadness, crying, and withdrawal from others of- ten are coupled with sleep and appetite disturbances. Loss of interest in sex, insecurities about sexual identity, sexual dys- function, and negative feelings toward men also are common (Goodman et al., 1993).

Many victims of sexual assault also blame themselves. Women may wonder if they unwittingly encouraged their assailant or chastise themselves for not being more cautious in avoiding dangerous circumstances. This irrational self-blame is abetted by cultural myths that women provoke rape or actually enjoy it. Sec- ondary victimization is a growing concern, as insensitive legal, medical, and even mental health professionals can add to a rape victim’s emotional burden. In fact, victims of acquaintance rape show increased symptoms of PTSD when they encounter victim- blaming behaviors from professionals who are supposed to help them (Campbell, 2008). Such findings may help explain why as many as two-thirds of stranger rapes and four-fifths of acquain- tance rapes are not reported to authorities.

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 181

the very worst traumas, and they pose an especially high risk for PTSD (see Figure 7.1).

Women are more likely than men to develop PTSD follow- ing trauma (Tolin & Foa, 2006). Sexual violence is a particular risk for women, while combat exposure is for men (Kessler et al., 1995; Prigerson, Maciejewski, & Rosenbeck, 2002). Children are especially vulnerable to trauma, with 20 to 40 percent developing PTSD (Neria & Galea, 2007). Minority group members are more likely to experience PTSD, in large part because of their more diffi- cult living conditions (Pole, Gone, & Kulkarni, 2008). PTSD also is common among crime victims (Kilpatrick & Acierno, 2003).

TrAumA IS noT rAnDom Whether people get caught in events like the Virginia Tech shootings is a matter of luck. Many traumas, however, do not occur at random. Because they engage in more risky behavior, men, young people, those with a his- tory of conduct disorders, and extroverts all are more likely to experience trauma. People who are anxious or who have a fam- ily history of mental illness also experience more trauma, but the reasons why are less clear.

The development of PTSD following a trauma also is not ran- dom. Those who are anxious and easily upset are more likely to de- velop PTSD after a trauma, as are people with a family or personal history of mental disorder (Breslau et al., 1998). In fact, a recent prospective study found that over 90 percent of those who devel- oped PTSD following trauma exposure met criteria for some other diagnosis earlier in their life (Koenen et al., 2008). People who de- veloped PTSD following an earlier trauma also are at greater risk following a second trauma (Breslau, Peterson, & Schultz, 2008). Despite the risks, resilience, successful psychological coping, is the most common human response to trauma (Bonanno et al., 2011).

courSe AnD ouTcome People who suffer from ASD symp- toms are more likely to develop PTSD (Bryant et al., 2010). Three symptoms—numbing, depersonalization, and a sense of reliving the experience—are the best predictors of future PTSD (Bryant & Harvey, 2000).

aftereffects. Five months after Hurricane Katrina in 2005, 22 percent of responding firefighters in New Orleans suffered from PTSD (CDC, 2006). In general, however, emergency workers are less than half as likely to develop PTSD as victims (Neria & Ga- lea, 2007). Emergency workers are protected by their training, preparation, and sense of purpose. More generally, hardiness, a sense of commitment, control, and challenge in facing stress, pre- dicts lower risk for PTSD (Sutker et al., 1995). Still, emergency workers need education about the psychological effects of trauma on them, opportunities to express troubling emotions, and, in some cases, specialized psychological help.

comorBIDITy Many people with PTSD also suffer from an- other mental disorder, particularly depression, anxiety disorders, and substance abuse (Brady, Back, & Coffey, 2004). Other co- morbid problems include disturbing nightmares, physical symp- toms like headaches and gastrointestinal problems, grief, and relationship difficulties (Cook et al., 2004). Anger—at others or at oneself—had been noted as another prominent issue (Orth & Wieland, 2006), which is why negative thoughts and emotions became a part of the new DSM-5 definition (Grant et al., 2008). Increased suicide risk also is notable. One study found that 33 percent of rape survivors had thoughts of suicide, and 13 percent actually made a suicide attempt (Kilpatrick, Edmunds, & Seymour, 1992).

Frequency of Trauma, PTSD, and ASD DSM once defined trauma as an event “outside the range of usual human experience.” Unfortunately, it is not. A random sample of 2,181 adults living in the Detroit area found that almost 90 percent had experienced at least one trauma in their lifetime. About 9 percent developed PTSD (Breslau et al., 1998; see Figure 7.1). A national study found that 6.8 percent of the people in the United States suffered from PTSD at some point (Kessler et al., 2005). Similar rates of trauma and PTSD also are found in Mexico (Norris et al., 2003). Rape and assault clearly are among

figure 7.1 Bars to the left of center indicate the percent- age of adults who had experienced each trauma among a representative sample of 2,181 adults aged 18 to 45 and living in the Detroit area. Bars to the right of center indicate the percentage of adults who developed PTSD after exposure to the particular trauma. Note: The prevalence of rape as reported in this study was lower than that reported in other studies. We assume that this statistic reflects only more violent rapes. Source: Based on data from “Traumatic and P osttraumatic Stress Disorder in the Community: The 1996 Detroit Area Survey of Trauma” by N. Breslau, R. C. Kessler, H. D. Chilcoat, L.R. Schultz, G. C. Davis, and P. Andreski, Archives of General Psychiatry, (1998), 55, pp. 626–632. Copyright © 1998. This material can be found at: http:// archpsyc.ama-assn.org/cgi/content/abstract/55/7/626. Reprinted by permission of American Medical Association.

5.4 49

6.2 23.7

11.4 31.9

14.3

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28 2.3

7.3

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100 80 60 40 20 0 10 20 30 40 50 60

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Experienced trauma PTSD following trauma

182 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

Social FactorS Research on social factors and the risk for PTSD focuses primarily on (1) the nature of the trauma and the individual’s level of exposure to it and (2) the availability of so- cial support following the trauma. Victims of trauma are more likely to develop PTSD when the trauma is more intense, life- threatening, and involves greater exposure (Neria & Galea, 2007). For example, victims of attempted rape are more likely to develop PTSD if the rape is completed, if they are physically in- jured during the assault, and if they perceive the sexual assault as life-threatening (Kilpatrick et al., 1989). Similarly, PTSD is more prevalent in Vietnam veterans who were wounded, who were in- volved in the deaths of noncombatants, or who witnessed atroci- ties (Koenen et al., 2003; Oei, Lim, & Hennessy, 1990). A study of PTSD following September 11 terror attack found a greater prevalence among people who lived south of Canal Street, close to the World Trade Center (Galea et al., 2002).

As with less severe stressors, social support after a trauma can play a crucial role in alleviating long-term psychological damage. A lack of social support is thought to have contributed to the high prevalence of PTSD found among Vietnam veterans (Oei et al., 1990). Rather than being praised as heroes, returning veterans often were treated with disdain. This made it difficult for many veterans to find meaning in their sacrifices and likely increased their risk for PTSD. People who had little social support also were more likely to develop PTSD following September 11 (Galea et al., 2002).

A study of identical twins strongly supports the role of the environment in PTSD. Among 715 monozygotic (MZ) twin pairs who were discordant for military service in Southeast Asia during the Vietnam War era, the prevalence of PTSD was nine times higher for co-twins who served in Vietnam and experienced high levels of combat in comparison to their identical twins who did not serve (Goldberg et al., 1990).

Biological FactorS The same twin study also strongly points to biological factors in PTSD. In an analysis of more than 4,000 twin pairs, MZ twins had a higher concordance rate for exposure to combat than dizygotic (DZ) twins. Follow- ing exposure, identical twins also had higher concordance rates

The symptoms of PTSD generally diminish with time. Symptoms improve fairly rapidly during the first year, but more gradually thereafter (see Figure 7.2). Symptoms diminish faster among people who receive treatment. Despite improvements, over one-third of people still report symptoms 10 years after the trauma, regardless of whether they were treated (Kessler et al., 1995).

PTSD can persist even longer. One study found symptoms among World War II prisoners of war—40 years after confinement. Only 30 percent of POWs who had suffered from PTSD were fully recovered; 10 percent either showed no recovery or had a deteriorat- ing course (Kluznik et al., 1986). Many victims of the Holocaust also show PTSD symptoms decades later. Still, even following exposure to the unbelievable horrors of the Holocaust, remarkable resilience is the most common outcome (Barel et al., 2010).

causes of PtSD and aSD By definition, trauma causes ASD and PTSD. Because not every traumatized person develops a disorder, however, trauma is a nec- essary but not a sufficient cause. What increases risk or resilience in the face of trauma?

MyPsychLab VIDEO CASE

Posttraumatic Stress Disorder

Bonnie

“I basically resigned myself to the fact that I was going to die.”

Watch the Video Bonnie: Posttraumatic Stress Disorder (PTSD) on MyPsychLab

As you watch the video, consider the terrible events Bonnie witnessed on 9/11.

Her PTSD symptoms make sense. What treatments might help her recover?

figure 7.2 The symptoms of PTSD decline over time but persist for 10 years among one-third of people. Treatment appears to hasten recovery, but this correlational finding may not mean causation. Source: Based on Kessler et al. 1995. Posttraumatic Stress Disorder in the National Comorbidity Survey. Archives of General Psychiatry; 52: 1057.

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acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 183

Police and participants react to the Boston Marathon bomb explosion. The DSM-5 defines trauma as an event that involves actual or threatened death, serious injury, or sexual violence to self, or witnessing others experience trauma, learning that loved ones have been traumatized, or repeatedly being exposed to details of trauma.

Preparedness, purpose, and the absence of blame can aid coping with trauma. Pilots cope more successfully with helicopter crashes if they have training than if they have none, underscoring the impor- tance of preparedness and control (Shalev, 1996). The value of pur- pose is supported by evidence that, despite greater physical suffering, political activists develop fewer psychological symptoms than non- activists following torture (Basoglu et al., 1997). On the other hand, negative appraisals—the rape victim who blames herself, or the driver who thinks he could have avoided an accident—are strongly tied to an increased risk for PTSD (Bonanno et al., 2011; Bryant & Guthrie, 2005; Halligan et al., 2003; McNally et al., 2003).

Over time, victims of trauma must find a balance between gradually facing their painful emotions while not being over- whelmed by them. New York City college students had lower rates of PTSD following the September 11 terrorist attack if they were better at enhancing and suppressing emotional expression (Bonanno et al., 2004). This illustrates what psychologist Edna Foa, a leading PTSD researcher, calls emotional processing, which involves three key steps. First, victims must engage emotionally with their traumatic memories. Second, victims need to find a way to articulate and organize their chaotic experience. Third, victims must come to believe that, despite the trauma, the world is not a terrible place (Cahill & Foa, 2007; Foa & Street, 2001).

This last step is similar to what other psychologists call mean- ing making—eventually finding some value or reason for having endured trauma (Ehlers & Clark, 2000). Meaning making is very personal and may involve religion, a renewed appreciation for life, or public service. Importantly, the search for meaning is as- sociated with more PTSD symptoms, whereas finding meaning is linked to better adjustment (Park, 2010). Stephanie found mean- ing in her efforts to make others more aware of sexual assault.

In the long run, many people actually report that trauma leads to growth (Tedeschi & McNally, 2011). Posttraumatic growth, pos- itive changes resulting from trauma, is linked with less depression

for PTSD symptoms than fraternal twins (True et al., 1993). Importantly, genetic contributions differed across symptoms. Genes contributed most strongly to arousal symptoms and least strongly to reexperiencing. Conversely, level of combat exposure predicted reexperiencing and avoidance but not arousal (True et al., 1993).

Does exposure to trauma have biological consequences as well as biological causes? People with PTSD show differences in the functioning, and perhaps the structure, of the amygdala and hippocampus. These findings are consistent with the experience of heightened fear reactivity and intrusive memories (Kolassa & Elbert, 2007). Other evidence links PTSD with general psycho- physiological arousal, for example, an increased resting heart rate (Pole, 2007). This suggests that the sympathetic nervous system is aroused and the fear response is sensitized in PTSD.

Does this mean that trauma damages the brain? A study of identical twins—one Vietnam veteran with PTSD and his co- twin who neither served in Vietnam nor suffered from PTSD— found smaller than average hippocampus volume in both twins (Gilbertson et al., 2002). Twin research shows that preexisting differences account for IQ deficits that have been mistakenly attributed to brain damage due to trauma (Gilbertson et al., 2006). Differences between people with and without PTSD are correlations—correlations apparently due to preexisting differ- ences, not due to brain damage caused by trauma.

PSychologIcAl FAcTorS Some theories suggested that dis- sociation is an unconscious defense that helps victims to cope with trauma (Oei et al., 1990). However, dissociation predicts more, not less PTSD (Ehlers, Mayou, & Bryant, 1998; Griffin, Resick, & Mechanic, 1997; Harvey et al., 1998). Among a sam- ple of Israeli war trauma victims, for example, more dissociation reported within one week following trauma predicted more severe PTSD six months later (Shalev et al., 1996).

184 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

CISD is difficult to evaluate, since it is conducted in the midst of a crisis (Tuckey, 2007). Still, research provides no evidence that CISD prevents future PTSD (Bryant & Harvey, 2000; McNally et al., 2003), and some studies find that CISD is actually harm- ful (Lilienfeld, 2007). CISD may provoke too much emotion too soon after trauma. Another problem is the CISD is unnatural. It is not offered by people who are a part of the victims’ world. CISD generally is provided by outsiders to groups of individuals who have no relationship to one another.

More naturalistic interventions show more promise. Since World War I, interventions with soldiers who drop out of combat have been based on the three principles of offering: (1) imme- diate treatment in the (2) proximity of the battlefield with the (3) expectation of return to the front lines upon recovery (Jones et al., 2007). The effectiveness of these principles was not studied systematically until a 1982 evaluation of the Israeli army during

and more positive well-being, but also with more intrusive and avoidant thoughts (Helgeson, Reynolds, & Tomich, 2006). Find- ing meaning in trauma does not mean forgetting about it.

integration anD alternative PathwayS There are multiple pathways to developing ASD and PTSD. Anyone might develop ASD or PTSD if exposed to a trauma of sufficient intensity. In other cases, trauma exacerbates or reveals a preexisting disorder. In most cases, ASD and PTSD develop as a result of a combination of factors, including trauma, personality characteristics that predate the trauma, exposure during the trauma, and emotional processing and social support afterwards (Ozer et al., 2003; Ozer & Weiss, 2004). We note again, however, that resilience is the most common outcome following trauma exposure (Bonanno et al., 2011).

Prevention and treatment of aSD and PtSD We know that trauma precedes ASD and PTSD. This leads to a very important question: Can we prevent the disorders with early intervention?

emergency helP For trauma victimS Many experts hope that prevention is possible. In fact, the U.S. Federal Emer- gency Management Agency (FEMA) provides special funding to community mental health centers during disasters. Emergency treatments range from intensive individual counseling sessions with hurricane victims to group discussions with children follow- ing school violence (Litz, 2004). Approaches differ greatly, but offering immediate support to trauma victims is a common goal (McNally et al., 2003; Raphael et al., 1996).

Perhaps the most widely used early intervention is critical in- cident stress debriefing (CISD), a single one- to five-hour group meeting offered one to three days following a disaster. CISD in- volves several phases where participants share their experiences and reactions, and group leaders offer education, assessment, and referral if necessary (Mitchell, 1982; Mitchell & Dyregrov, 1993).

Students gather for a vigil following the Virginia Tech shootings. For many, shared grief and support eases the pain of trauma and reduces the risk for PTSD.

MyPsychLab VIDEO CASE

Posttraumatic Stress Disorder

SArA

“I would wake up 37 times a night for the slightest noise, thinking this crazy person was going to come in and do something to me.”

Watch the Video Sara: Posttraumatic Stress Disorder on MyPsychLab

As you watch the video, listen for Sara’s description of her PTSD symptoms: arousal, avoidance, and reexperiencing. Also consider ways in which the trauma of domestic violence is unique—for example, in the social isolation of the victim.

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 185

conditions produced a significant reduction on the PTSD Check- list (PCL), but only among soldiers exposed to a large number of combat events (Adler et al., 2009).

cognitive Behavior theraPy For PtSD While great sensitivity is required, the most effective treatment for PTSD is therapeutic reexposure to trauma (Foa, Gillihan, & Bryant, 2013). One of the first studies of prolonged exposure asked rape victims to relive the trauma repeatedly over nine therapy sessions. While surely painful, exposure reduced PTSD symptoms more, over the long term, than three randomized alternatives, including relax- ation/stress management, supportive counseling, and a wait list control group (Foa et al., 1991). Among other trauma, prolonged exposure has now been successfully used for PTSD following combat (Monson et al., 2006), childhood sex abuse (McDonagh et al., 2005), and assault (Foa et al., 2005).

Depending on the client, the therapist, and the circumstances of the trauma, prolonged exposure might involve confronting feared situations in real life, in one’s imagination, or by recount- ing events in therapy (Foa et al., 2013). One treatment, imagery rehearsal therapy, successfully reduces recurrent nightmares, a trou- bling problem frequently associated with PTSD. The exposure involves reliving nightmares while awake, but rewriting the night- mare script in any way the client wishes (Krakow et al., 2001).

Across studies, approximately 50 percent of patients still meet diagnostic criteria after treatment with prolonged expo- sure (Resick et al., 2007), as do about 20 percent at 5- to 10-year follow-up (Resnick et al., 2013). Prolonged exposure is the most strongly supported treatment for PTSD (Foa et al., 2013), but perhaps treatment is the beginning, not the end, of the healing

the Lebanon war. Results indicated that 60 percent of soldiers treated near the front recovered sufficiently to return to battle within 72 hours. Soldiers who expected to return to the front experienced lower rates of PTSD than did those who did not. Soldiers who were treated on the front lines also were less likely to develop PTSD subsequently compared to soldiers who were treated away from the battlefield (Oei et al., 1990).

Former Mayor Rudolph Giuliani intuitively followed similar principles when, in the immediate aftermath of September 11, he regularly encouraged New Yorkers to grieve but also to go back to work, to go out, and to go on despite the horrors of the World Trade Center attacks. Such community-based efforts are more appealing, and perhaps more effective, than artificial debriefings. Consider this: Government agencies allocated over $150  million to pay for psy- chotherapy for New Yorkers in the wake of September 11, but $90 million remained unspent two years later ( McNally et al., 2003).

A study of veterans returning from a year-long deployment in Iraq shows the promise of more naturalistic interventions in preventing PTSD symptoms (Adler et al., 2009). Soldiers were randomly assigned to (1) the army’s “treatment as usual,” stress education in groups of about 100, (2) battlemind debriefing, dis- cussions in groups of 20 to 32 that included some review of com- bat experiences but focused on the transition home and building peer support, and (3) battlemind training, focused on finding inner strength in combat, teaching skills to help unit members, and reframing redeployment difficulties as normal problems that require adapting occupational coping skills. Battlemind training was offered both in small (18 to 45 individuals) and large (126 to 225 individuals) groups to control for the potential confound of group size. As portrayed in Figure 7.3, all three experimental

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figure 7.3 PtSD Symptoms among Soldiers returning from iraq: effects of Four Prevention Programs Battlemind debriefing and battlemind training (in small and large groups) significantly reduced symptoms measured on the PTSD Checklist (PCL) when compared to stress education, but only among soldiers exposed to high levels of combat. These results support the benefits of more naturalistic prevention efforts directed toward groups most at risk. Source: A. B. Adler, et al., “Battlemind debriefing and battlemind training as early interventions with soldiers returning from Iraq: Randomized by platoon.” Journal of Consulting and Clinical Psychology, 77, 937. Copyright © 2009, American Psychological Association.

186 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

which were widely read books that became popular motion pic- tures. In recent years, psychological scientists have grown more interested in unconscious mental processes (Bargh & Morsella, 2008). Partially as a result, interest in dissociative disorders also has grown—without resolving basic controversies. We introduce these problems, and the debate, in the following case study.

Dissociative Fugue—Dallae’s Journey Dallae disappeared mysteriously in the middle of final exams dur- ing her junior year at a California university. Her roommate last saw her studying for her organic chemistry exam. Dallae had been agitated that night. She kept bothering her roommate, who was cramming for the same exam, and left her room repeatedly. Dal- lae did not take the exam the next day. When she missed two more finals, her roommate contacted the authorities.

At first, the police suspected foul play, because it seemed un- likely that Dallae would leave college on her own. None of her per- sonal possessions was missing; even her eyeglasses were still sitting on her desk. However, bank records indicated that Dallae withdrew all of her money from her bank account the day before the exam. Investigators also discovered that Dallae had told her parents that she had an A in organic chemistry. In fact, she was failing the course.

When the local police failed to locate Dallae, they contacted the FBI. After a four-week investigation, they found Dallae in a college town on the East Coast. She had been brought to a hos- pital emergency room after she was found wandering the streets. She appeared confused and disoriented. She told the emergency room (ER) physician that her name was Dawn and that she had been living on the streets and sleeping in dormitory lounges. She said that she had just moved from the West Coast and had come to the town because she hoped to attend the university. She gave a vague account of other details of her life. For example, she could not say how she got to the East Coast.

Dallae allowed herself to be voluntarily admitted to the hospi- tal’s psychiatric unit. There she talked little and spent most of her time watching television. She told the staff that she was Vietnam- ese and had been adopted by American parents, but her stories remained vague and inconsistent. She said that she could not re- member many things, but she was not upset by her impairment. A CAT scan and neuropsychological tests detected no physical ab- normalities or deficits in short-term memory or motor functioning.

A hospital social worker contacted the local police about the dis- oriented young patient, and the police were able to identify Dallae from a missing persons report. The social worker contacted Dallae’s parents, and her mother immediately flew east to see her. When her mother appeared at the hospital, Dallae did not recognize her. Her mother was greatly distressed by Dallae’s indifference and noted other oddities and inconsistencies. For one thing, Dallae was not Viet- namese, and she was not adopted. She had grown up with her mar- ried parents, who were Korean immigrants. Her mother also noted

process. Meaning making is ultimately a reframing and reinter- pretation of the experience of trauma. Perhaps this is more than what can be expected from any therapy.

emDr One treatment for PTSD, eye movement desensitization and reprocessing (EMDR), is a technique that has been greeted with considerable enthusiasm—and skepticism. Psychologist Francine Shapiro (1995) “discovered” that rapid back-and-forth eye move- ments reduced her own anxiety, so she tried the technique on her clients, who appeared to benefit from it. Why should this work? No one has a good theory why, which is the heart of the con- troversy (Keane, Marshall, & Taft, 2006). Still, Shapiro and other proponents use EMDR as a relaxation technique, while clients with PTSD simultaneously relive vivid images of trauma. A recent meta-analysis concluded that EMDR may be effective (Bisson et al., 2007); however, prolonged exposure, not eye movements, appears to be the “active ingredient” (Foa et al., 2013).

TreATmenT oF ASD Research shows that structured interventions with ASD can lead to the prevention of future PTSD (Bryant et al., 2010). Unlike CISD, these treatments last longer and target the se- lect group of trauma victims who meet ASD diagnostic criteria. The evidence based ASD treatments use principles of cognitive behavior therapy, although they are briefer, typically involving five 90-minute sessions (Bryant et al., 2006; Bryant, Moulds, & Nixon, 2003).

AnTIDePreSSAnT meDIcATIon Numerous practice guide- lines recommend antidepressants (SSRIs) as a treatment for PTSD (Friedman & Davidson, 2007). The effectiveness of SSRIs is likely at least partially due to the high comorbidity between PTSD and depression (Newport & Nemeroff, 2000). While anti- depressants are helpful, only about 30 percent of treated patients recover fully from PTSD symptoms (Friedman, Resick, & Keane, 2007). Traditional antianxiety medications are not effective for PTSD (Golier, Legge, & Yehuda, 2007).

Dissociative Disorders While dissociation in ASD and PTSD can be dramatic, the symp- toms of dissociative disorders—characterized by persistent, mal- adaptive disruptions in the integration of memory, consciousness, or identity—verge on the unbelievable. They include psychologi- cally produced amnesia, confused travel of long distances from home (perhaps under a new identity), and the existence of two or more separate personalities in one person. Are these symptoms real? The answer is controversial. Some experts think dissociative disorders are phony, examples of nothing more than the power of suggestion. Others view them as real but rare problems. Still oth- ers believe dissociative disorders are misunderstood, overlooked, and prevalent. This controversy is about much more than dissocia- tive disorders. It concerns the very nature of the human psyche.

Dissociative disorders sometimes are of more interest to novelists than to scientists. You may be familiar with dramatic portrayals of multiple personality disorder, an old name for a dis- sociative disorder, in Sybil1 or The Three Faces of Eve, both of

1A review of tapes of a few of Sybil’s sessions concluded that her “alters” were implanted by her therapist. Sybil reportedly confessed that she created her alters to please her therapist (Rieber, 2006).

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 187

hysteria and the unconscious Historically, dissociative disorders (and some somatic symptom disorders, which we discuss shortly) were viewed as forms of hysteria. In Greek, hystera means “uterus,” and the term hysteria reflects the ancient view that frustrated sexual desires, particularly a woman’s desire to have a baby, cause the unusual symptoms. Ancient beliefs held that the uterus detached and moved about the body, causing a problem wherever it eventually lodged. This strange be- lief lived well into the late nineteenth century, when many experts argued that hysteria occurred only among women (Showalter, 1997).

chArcoT, FreuD, AnD JAneT In the latter half of the nineteenth century, French neurologist Jean-Martin Charcot used hypnosis both to induce and treat hysteria. Charcot greatly influ- enced Sigmund Freud, who observed Charcot’s hypnotic treatments early in his training. Charcot also strongly influenced Freud’s con- temporary and rival, Pierre Janet (1859–1947). Janet was a French philosophy professor who conducted psychological experiments on dissociation and who later trained as a physician in Charcot’s clinic.

Both Janet and Freud were eager to explain hysteria, and both developed theories of unconscious mental processes to do so. Their theories differed sharply, however. Janet saw dissociation as an abnormal process. To him, detachment from conscious aware- ness occurred only as a part of psychopathology. In contrast, Freud considered dissociation to be normal, a routine means for the ego to defend itself against unacceptable unconscious thoughts. Freud saw dissociation and repression similarly. In fact, he often used the two terms interchangeably (Erdelyi, 1990). Thus, Freud viewed hysteria merely as one expression of unconscious conflict.

The two theorists criticized each other frequently. Janet thought that Freud greatly overstated the importance of the un- conscious; Freud thought that Janet greatly underestimated it. However, Janet’s work became increasingly obscure over time, as Freudian theory dominated throughout much of the twentieth century. As Freudian influences have declined, scholars have re- discovered Janet’s contributions and his more narrow conception of dissociation and unconscious mental processes.

that although Dallae was right-handed, she used her left hand to write a note at the hospital. Dallae’s consistent use of her left hand was con- firmed by the staff and by the neuropsychologist who had tested her.

Two nights after her mother arrived, Dallae’s memories ap- parently returned. That night, she attempted suicide by slashing her wrists, but she was discovered by a hospital staff member, who quickly stopped the bleeding. Dallae was intermittently depressed and extremely agitated for the next several days, es- pecially after seeing her mother. Although she would not talk at length, her conversation indicated that much of her memory was now intact, and she began using her right hand again.

During the next two weeks, Dallae gradually related details about her life to the psychologist who was treating her. Dallae had been a quiet and obedient girl all through her childhood. Her parents worked very hard and had high ambitions for their three children. Dallae’s older brother had an M.B.A. and was a successful young executive. Her older sister currently was editor of the law review at a prestigious law school. Throughout her life, her parents had told friends and relatives that Dallae would be a doctor one day.

During discussions with her therapist, Dallae began to talk more freely. She noted that she had been terrified to tell her par- ents, especially her father, about her grades and her lack of interest in medicine. She cried at length when relating how he had struck her across the face during the previous Thanksgiving break, when she tried to tell him that she no longer wanted to study medicine.

After six weeks in the hospital, Dallae returned to California with her parents. Her memory was intact at the time of the discharge, ex- cept that she continued to have no recollection of her trip across the country or many of her days living on the streets. She was uncertain why she thought her name was Dawn. She did mention being vaguely influenced by a television show about a Vietnamese child who had been adopted. At the time of Dallae’s discharge, her depression had abated, and she was no longer actively suicidal. She reported being relieved at having told her mother about her feelings about medical school, but she remained very anxious about facing her father.

Dallae suffered from dissociative fugue, which is characterized by sudden, unplanned travel, the inability to remember details about the past, and confusion about identity or the assumption of a new identity. The travel is purposeful. Despite her confusion and memory impairments, Dallae knew where she was going and pro- vided at least a vague explanation about why. Dissociative fugue typically follows a traumatic event. It perhaps is most commonly observed among soldiers following a particularly gruesome battle.

Purposeful travel is the distinguishing symptom, but the core questions about fugue—and about all dissociative disorders— concern the split between conscious and unconscious psychologi- cal experience. How could Dallae be aware of the present but be unaware of her past? Why didn’t all her memories return after she saw her mother? Could she be faking part or all of her “illness”? Key figures in the history of abnormal psychology have tried to answer such perplexing questions.

The French neurologist Jean Charcot (1825–1893) demonstrating a case of hysteria at the Salpêtrière, a famous hospital in Paris.

188 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

CrITICAL ThInkIng matters

Recovered Memories?

In 1990, George Franklin was convicted of the brutal murder of an eight-year-old girl. The crime occurred over 20 years earlier. The major evidence was the “recovered memory” of Franklin’s daughter Eileen. Eileen claimed she had witnessed her father commit a rape and murder, but dissociation pushed the memory into her unconscious mind. Twenty years later, according to the daughter, the memory returned.

Eileen provided both verifiable and inconsistent accounts of the horrifying event. She recalled a smashed ring on her friend’s finger as she raised her hand to protect herself from a blow with a rock. Records corroborated the incident. On the other hand, Eileen changed her story about the time of day and whether her sister also was with them. Based solely on his daughter’s testimony, George Franklin was convicted. However, his conviction was over- turned in 1995, and he was released from prison. A U.S. District Court judge ruled that the lower court erred in excluding evidence that Eileen could have learned details of the 1969 murder from newspaper articles. The prosecutor decided not to retry the case when Eileen’s sister revealed they both were hypnotized before the first trial—a fact Eileen lied about. Eileen also had accused her father of a second murder, but DNA evidence cleared him.

Was Eileen’s memory fact or fiction? Our concern about so-called recovered memories extends well beyond the Franklin case. In the 1990s, as many as 25 percent of therapists said that recover- ing memories, particularly of sexual abuse, was an important part of their therapy with female clients (Poole et al., 1995). Popular books also have encouraged people to search for (create?) mem- ories. For example, in The Courage to Heal, the authors stated:

To say “I was abused,” you don’t need the kind of recall that would stand up in a court of law. . . . Often the knowl- edge that you were abused starts with a tiny feeling, an intuition. It’s important to trust that inner voice and work from there. Assume your feelings are valid. So far, no one we’ve talked to thought she might have been abused and then later discovered that she hadn’t been. (Bass & Davis, 1988, p. 22)

Could such suggestions lead some people to create memories about events that never happened? Faced with accusations of past abuse, many parents say that misguided therapists have created false memories. In fact, the term, false memory syn- drome, was coined to account for the implanting of false beliefs (Kihlstrom, 1998a).

Research shows that memories, even of highly dramatic events, can be inaccurate (Loftus, 2003, 2004). In one study, researchers interviewed people the day after the space shuttle Challenger exploded and detailed how participants learned of the tragedy. Three years later, they asked the same people to remember what they were doing. About one-third reported vivid and grossly inaccurate memories (Neisser & Harsch, 1992). In another study, researchers created false memories of “sliming” a first- or second-grade teacher (putting slime in the teacher’s desk)—among 65 percent of the participants! The key to the deception was using actual school photos to help participants to “ remember” (Lindsay et al., 2004). Such research does not prove that recovered memories of trauma are false (Gleaves et al., 2004). In fact, recent experimental research shows that laboratory- induced interference and subsequent cuing can produce forget- ting and remembering, respectively (Smith & Moynan, 2008). Still, the malleability of memory suggests many reasons for skepticism.

There certainly are good reasons to question the validity of “recov- ered memories” from early in life, since few people can report any accurate memories before age three or four (Loftus, 2003, 2004). The fact that people are especially likely to remember emotionally intense events is another reason to think critically about claims of recovered memories. Some documented victims of sexual abuse do not recall the experience many years later (Williams, 1994), but most do remember what happened (Goodman et al., 2003). And, of course, documented cases of forgetting do not prove that un- documented cases of remembering are accurate.

Are some claims of recovered memories more accurate than oth- ers? A recent study found that memories that returned outside of therapy were more likely to be corroborated than memories “recovered” in therapy (Geraerts et al., 2007). Sadly, some pa- tients with recovered memories apparently are victims of their therapists, not of abuse.

Where were you when the World Trade Center towers collapsed? Researchers find that even powerful “flashbulb” memories of dramatic events often grow inaccurate over time.

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 189

Contemporary scientists also have developed new methods to study unconscious processes. Consider the distinction between ex- plicit and implicit memory. Explicit memory is conscious recollec- tion. Implicit memory is unconscious and evident only because past experience can change behavior (Schacter, 1987). For example, the implicit association test reveals implicit memories by compar- ing response times to cues. Black and good versus white and good would be an example. Quicker responses reflect established associ- ations in memory. We respond automatically and quickly to asso- ciations that implicitly “make sense.” Evidence shows that implicit attitudes about delicate subjects like racial prejudice differ consid- erably from explicitly reported beliefs (Ratliff & Nosek, 2010).

Exciting new methods like the implicit association test allow psychological scientists to go beyond making assertions about the unconscious mind and to actually study it. Unfortunately, avail- able methods are too limited to truly test bold assertions about the unconscious that we consider in this chapter, like the true nature of hypnosis and dissociative disorders.

Symptoms of Dissociative Disorders The extraordinary symptoms of dissociative disorders apparently involve mental processing outside of conscious awareness. Ex- treme cases of dissociation include a split in the functioning of the individual’s entire sense of self. In dissociative identity disorder (DID), two or more personalities coexist within a single individ- ual. Unless we assume that the symptom is feigned, dissociative identity disorder demonstrates that the mind can function on multiple levels of consciousness.

Depersonalization is a less dramatic symptom where people feel detached from themselves. One example is an out-of-body experience, such as the sensation of floating outside yourself and watching your actions as if you were another person. Derealiza- tion is a related symptom that involves feelings of unreality or de- tachment from the environment, such as experiencing the world as being more dreamlike than real.

Another dramatic example is dissociative amnesia—the partial or complete loss of recall for particular events or for a particular period of time. Brain injury or disease can cause amnesia, but dis- sociative amnesia results from trauma or severe emotional distress. Dissociative amnesia may occur alone or in conjunction with other dissociative experiences. For example, in dissociative identity disor- der one personality may report that it does not remember the ac- tions, or even the existence, of another (Spiegel & Cardena, 1991). Recent laboratory evidence calls self-reports of amnesia into ques- tion, however, as DID patients show transfer of memories between identities on experimental tasks (Kong, Allen, & Glisky, 2008).

TrAumA AnD DISSocIATIve SymPTomS Dissociative am- nesia is widely viewed as being caused by trauma, as is the disso- ciative fugue that sometime accompanies it. The trauma usually is clear and sudden, and after a time, psychological functioning rapidly returns to normal in most cases. Much more controversial is the role of trauma in DID. Some argue that DID is linked

hyPnoSIS: AlTereD STATe or SocIAl role? A topic of historical importance and contemporary debate about the uncon- scious mind is the nature of hypnosis, in which subjects experience loss of control over their actions in response to suggestions from the hypnotist. All agree that demonstrations of the power of hyp- notic suggestion are impressive, and that different people are more or less susceptible to hypnosis. However, some experts assert that hypnosis is a dissociative experience, an altered state of conscious- ness. Others argue that hypnosis is merely a social role, a subject voluntarily complying with suggestions due to social expectations (Barnier, 2002; Kihlstrom, 1998b; Kirsch & Lynn, 1998; Woody & Sadler, 1998). Beware of concluding that hypnosis must be real and powerful because you have seen it at work in a group demonstra- tion. Hypnotists select highly susceptible (or highly compliant!) participants from a large group for demonstration purposes. How? They usually give a small suggestion to the entire group, like closing your eyes and imagining that a helium balloon is tied to your hand. If your arm flies in the air, you’re a candidate for coming on stage.

PSychologIcAl ScIence AnD The unconScIouS Most psychological scientists today agree that unconscious mental pro- cesses play a role in both normal and abnormal emotion and cog- nition (Bargh & Morsella, 2008). We remember a phone number, for example, without knowing how we accessed the memory. However, scientists debate the importance of unconscious pro- cessing. Some cognitive scientists call the unconscious mind “dumb,” not “smart” (Loftus & Klinger, 1992), that is, of lim- ited importance. Others propose elaborate models of unconscious mental processes—for example, that we have two systems of in- formation processing (Epstein, 1994). The rational system uses abstract, logical knowledge to solve complex problems over time. The experiential system uses intuitive knowledge to respond to problems immediately without the delay of thought. The uncon- scious experiential system is hypothesized to be emotional, pow- erful, and often illogical (Epstein, 1994). Rationally, we might know that airplanes are safer than automobiles, for example, but emotionally, we are more likely to fear flying.

Hypnotized college students reacting to the suggestion that they are on a beach in Hawaii. Performance hypnotists produce such dramatic effects by selecting only highly suggestible subjects for their demonstrations.

190 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

firefighter reminded him that they had embraced in the com- mand center of the South Tower shortly before it collapsed, Shea remembered the event. However, no memories returned when Shea met another firefighter who himself was injured while trying to rescue Shea.

It is unclear whether Shea suffered from dissociative amnesia due to the emotional trauma of the day, or whether his memory loss was caused by a blow to his head. Although by all accounts Kevin Shea was a hero, he had trouble convincing himself of the truth of this assessment, because he could not remember his own actions on September 11.

Depersonalization/derealization disorder is characterized by feelings of being detached from oneself or the world around you. Occasional experiences of depersonalization or derealiza- tion, such as feelings of déjà vu, are normal and are reported by about half the population. In depersonalization/derealization disorder, the symptoms are persistent or recurrent and cause marked personal distress. The onset of the disorder commonly follows a new or disturbing event, such as drug use. All deper- sonalization and derealization experiences are “as-if ” feelings, not delusional beliefs. You feel as if you are a robot; you don’t really believe it. In fact, some experts question whether the problem should be considered a dissociative disorder, because it involves only limited splitting between conscious and uncon- scious mental processes, and no memory loss occurs (Spiegel & Cardena, 1991).

with past, not present, trauma, particularly with chronic physi- cal or sexual child abuse (Gleaves, 1996). Many psychological scientists are skeptical about this assertion, however, because information about childhood trauma is based solely on clients’ reports—reports that may be distorted by many factors, including a therapist’s expectations (Kihlstrom, 2005). A related controversy concerns so-called recovered memories, dramatic recollections of long-ago traumatic experiences supposedly blocked from the con- scious mind by dissociation (see Critical Thinking Matters box).

Diagnosis of Dissociative Disorders DSM-5 lists three types of dissociative disorders: dissociative amnesia, depersonalization disorder, and dissociative identity disorder. Dissociative amnesia involves a sudden inability to re- call extensive and important personal information that exceeds normal forgetfulness. Patients typically suffer from selective amnesia—they do not lose all of their memory but instead can- not remember selected events and information, often related to a traumatic experience. The memory loss is not attributable to substance abuse, head trauma, or a cognitive disorder, such as Alzheimer’s disease. A subtype of dissociative amnesia involves dissociative fugue, sudden and unexpected travel, associated with amnesia about identity or other important information. Dissociative amnesia and fugue typically have a sudden onset following trauma or extreme stress and an equally sudden recov- ery of memory. The following case study provides one dramatic a ccount, based on an article written by David Grann for the New York Times (January 13, 2002). Watch the Video Sharon: Dissociative Amnesia on MyPsychLab

Amnesia for September 11 Kevin Shea, a firefighter for the Fire Department of New York, was one of the very few survivors rescued from the wreckage of the World Trade Center. On the evening of September 11, Shea was found buried under a pile of rubble, his thumb severed and his neck broken in three places. Fortunately, Shea was not paralyzed by his spinal injury, but, like his neck, Shea’s memory was badly fractured.

Shea could remember his past and a few events from early on the day of September 11. For example, he could remember volunteering to help, even though he was off duty, and jumping on his firehouse’s Engine 40 to rush downtown. As the engine ap- proached the scene, he remembered seeing people falling from high floors of the towers. After this, however, Shea had no real memory of September 11, not until after he was hospitalized late in the day. For example, he had no memory of either tower col- lapsing, even though he was there at the horrifying, chaotic scene.

Shea lost every member of his engine in the WTC rescue attempt. He became desperate to learn that he survived de- spite trying to save others and not because he instead focused on saving himself. Through diligent efforts in the months af- ter September 11, he was able to piece together some evi- dence about what happened to him. Some details brought back fragments of his memory. For example, when another

Kevin Shea, a firefighter for the FDNY, received numerous injuries, including a broken vertebrae, working as a rescue worker during the World Trade Center attacks. Shea also suffered from amnesia, perhaps as a result of a blow to the head or perhaps from emotional causes.

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 191

intellectual personality (Sizemore & Pittillo, 1977). Sizemore has written several books about her life, and, as a well-functioning, unified personality, she has become a spokesperson for mental health concerns. In her book A Mind of Her Own, she offers the following observations on her personalities:

Among these twenty-two alters, ten were poets, seven were artists, and one had taught tailoring. Today, I paint and write, but I cannot sew. Yet these alters were not moods or the result of role-playing. They were entities that were totally separate from the personality I was born to be, and am today. They were so different that their tones of voice changed. What’s more, their facial expressions, ap- petites, tastes in clothes, handwritings, skills, and IQs were all different, too (Sizemore, 1989, p. 9).

The case of Chris Sizemore dramatically illustrates the characteristics of DID. Sizemore’s words also foreshadow controversies about the condition. Some professionals argue that DID is nothing more than role playing; others assert that multiple personalities are very real and very common. While controversy centers on DID, skepticism abounds

To many people, the most fascinating dissociative disorder is dissociative identity disorder (DID), a condition formerly known as multiple personality disorder. This extremely unusual problem is characterized by the existence of two or more distinct personalities in a single individual. Two or more of these person- alities repeatedly take control of the person’s behavior, with altera- tions in mood, behavior, and at least some loss of recall between the personalities. The original personality especially is likely to have amnesia for subsequent personalities, which may or may not be aware of other “alters” (Aldridge-Morris, 1989). Recent case studies claim to have identified more and more alters. The case of “Eve,” published in 1957, identified three; “Sybil” was reported to have 16 in a 1973 best-seller (the veracity of which has been questioned; Nathan, 2012); and some more recent case stud- ies have “discovered” 100, even 1,000, alters. Not surprisingly, such claims have generated more debate about a controversial diagnosis.

The Three Faces of Eve A famous case study of multiple personality disorder is Thigpen and Cleckley’s book (1957) that was adapted into The Three Faces of Eve, a motion picture. Thigpen and Cleckley, two psy- chiatrists who treated the young woman, described Eve White as a young mother with a troubled marriage who sought psy- chotherapy for severe headaches, feelings of inertia, and “black- outs.” Eve White was seen for several therapy sessions and was hypnotized during this time as a treatment for her amnesia. Then, during what proved to be a remarkable session, Eve White be- came agitated and complained of hearing an imaginary voice. As Thigpen and Cleckley wrote, “After a tense moment of silence, her hands dropped. There was a quick, reckless smile and, in a bright voice that sparkled, she said, ‘Hi there, Doc!’” (p. 137). Eve Black had emerged—a carefree and flirtatious personality who in- sisted upon being called “Miss” and who scorned Eve White, the wife and mother.

Therapy with Eve White, Eve Black, and a third, more calm and mature personality, Jane, lasted over two-and-a-half years. Thigpen used hypnosis to bring out the different personalities in an attempt to understand and reconcile them with one another. He eventually adopted the goal of fading out the two Eves and allowing Jane to take control. Therapy appeared to be success- ful. According to the psychiatrists’ account, treatment ended with one integrated personality in control. This personality was much like Jane, but she decided to call herself “Mrs. Evelyn White.”

But the end of therapy with Thigpen and Cleckley was not the end of therapy for “Eve.” Eve, whose real name is Chris Sizemore, claims to have had a total of 22 different personali- ties, some of which developed before her treatment with Thig- pen and Cleckley and some of which developed afterward. The personalities always occurred in groups of three, and they always included a wife/mother image, a party girl, and a more normal,

Chris Sizemore is “Eve” from the book and the movie The Three Faces of Eve, based on her psychiatrists’ account of her life and treatment for multiple per- sonality disorder. Sizemore is now cured and is an advocate for the mentally ill.

192 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

Frequency of Dissociative Disorders These controversies contribute to widely varying estimates of the prevalence of dissociative disorders. Most experts consider the problems to be extremely rare. Only about 200 case histo- ries of DID were reported in the entire world literature prior to 1980 (Greaves, 1980). Surely as a result of Sybil influences, the estimated number skyrocketed to about 40,000 in the next two decades (Pintar & Lynn, 2008). A small but vocal group of professionals has argued that many patients suffering from dissociative disorders are misdiagnosed as having schizophre- nia, borderline personality disorder, depression, panic disorder, or substance abuse (Gleaves, 1996; Ross, 2009). One study claimed that over 10 percent of the general adult population suffers from a dissociative disorder—including 3 percent of adults with DID (Ross, 1991). The same author claimed that 40 percent of hospitalized psychiatric patients met earlier DSM criteria for the diagnosis of a dissociative disorder (Ross, Duffy, & Ellason, 2002). These estimates are stunning—so stunning as to be unbelievable. Perhaps even more stunning is that DSM-5 includes an estimated prevalence of DID of 1.5 percent, while offering the disclaimer that the number is based on a “small study” (DSM-5, 2013; see Thinking Critically about DSM-5).

Clearly, experts either missed tens of thousands of cases of dissociative disorders for decades, or some advocates have been overzealous in defining dissociative disorders. Research suggests

about all dissociative disorders. Little evidence supports the validity of dissociative amnesia (McNally, 2003). As in the case of Kevin Shea, dissociative amnesia and fugue may be attributable to neurological conditions (Kihlstrom, 2005). Finally, very little research has been completed on the seem- ingly less controversial problem of depersonalization disor- der (Geisbrecht et al., 2008).

Thinking CriTiCally about DSM-5

More on Diagnostic Fads

Fads come and go. Hula hoops. Pet rocks. Platform shoes. iPods. Piercing various body parts. Tattoos. When we look back on them, fads can be embarrassing. You should see pictures of our long hair during our hippie days. But perspective is hard to obtain in the middle of a fad craze. Right now, DSM–5 diagnoses are “in.”

Do fads really develop for psychological diagnoses? Doesn’t sci- ence make the field immune? The short answers are “yes” and “no.”

Allen Frances, the psychiatrist who was in charge of the fourth revision of the DSM, has one big worry about DSM-5 fads. We are diagnosing everything, turning normal quirks, disappoint- ments, and stress into mental disorders. In his book, Saving Nor- mal, Frances (2013) critiques many of DSM-5’s specific changes. More broadly, he worries that the faddish rise in diagnosing mental disorders is stigmatizing far too many people, helping the pharmaceutical industry promote drugs for all kinds of nor- mal life problems, and helping to break family and national bud- gets with health care expenditures. Frances is intensely critical,

sometimes over the top. DSM-5 is embracing science. The goal is to help more people, and help them better, by crafting clearer and more accurate diagnoses. But Frances also has a point. The diagnosis of mental disorders is exploding, and that is not always or necessarily a good thing—even though we can have a hard time seeing or admitting to problems when a fad is “hot.”

Two topics that we discuss in this chapter were “hot” in the 1990s: Dissociative disorders and recovered memories. As you have read, the recovered memory movement has been largely discredited. But a 1995 study found that 25 percent of therapists said that recovering memories, particularly of sexual abuse, was an important part of their therapy with female clients (Poole et al., 1995). Not a problem? Read about the Franklin case in Critical Thinking Matters. And a 1991 study claimed that 3 per- cent of adults suffered from dissociative identity disorder (Ross, 1991), when only about 200 case histories of multiple personal- ity were reported in the entire world literature prior to 1980 (Greaves, 1980). Some work has been published on dissociative identity disorders since the 1990s, but almost all cases can be at- tributed to a small group of clinicians, there are almost no other

© Gabriel Utasi

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 193

other rape-murder cases where victims were left naked on the hillsides of Los Angeles. Considerable evidence supported Bian- chi’s guilt, but he reported frequent episodes of “blanking out,” including an inability to remember events from the night that the murders were committed. At the request of his attorney, Bianchi was seen by a mental health expert, who hypnotized Bianchi and suggested to him, “I’ve talked a bit to Ken, but I think that per- haps there might be another part of Ken that I haven’t talked to, another part that maybe feels somewhat differently from the part I’ve talked to. And I would like to communicate with that other part” (Watkins, 1984). Bianchi responded that he was not Ken, but Steve. Steve knew of Ken, and he hated him. Steve also con- fessed to strangling “all of these girls.”

Numerous experts who interviewed Bianchi disagreed about whether his apparent DID was real or feigned. One was

many reasons to disbelieve claims that dissociative disorders are prevalent and overlooked (Kihlstrom, 2005; Piper & Merskey, 2004a, 2004b):

• Most cases of dissociative disorders are diagnosed by a hand- ful of ardent advocates.

• The frequency of the diagnosis of dissociative disorders in general, and DID in particular, increased rapidly after release of the very popular book and movie Sybil.

• The number of personalities claimed to exist in cases of DID grew rapidly, from a handful to 100 or more.

• Interest in dissociative disorders declined beginning in the middle of 1990s (after Sybil ), as specialized treatment units closed and professionals withdrew from organizations and journals devoted to the topic.

• Dissociative disorders are rarely diagnosed outside of the United States and Canada; for example, only one unequivo- cal case of DID has been reported in Great Britain in the last 25 years (Casey, 2001).

• The symptoms of dissociation in the most commonly used instruments like the Dissociative Experiences Questionnaire are far less dramatic than those found in dissociative disor- ders (Geisbrecht et al., 2008; see Table 7.1).

DISorDer or role enAcTmenT? Some experts even doubt the very existence of DID, arguing that DID is created by the power of suggestion (Piper & Mersky, 2004a, 2004b). The Canadian psychologist Nicholas Spanos (1942–1994) was a par- ticularly outspoken critic. He argued that multiple personalities are caused by role playing. Influenced by their own and their ther- apists’ expectations, Spanos (1994) argued that, like an actor who loses all perspective, patients come to believe that the role is real.

To test his theory, Spanos and his colleagues conducted analogue experiments inspired by the case of Kenneth Bianchi, the infamous “Hillside Strangler.” In 1979, Bianchi was charged with murdering two college women and was implicated in several

documented cases, and laboratory simulations of DID are almost indistinguishable from identified cases (Boysen & VanBergen, 2013). A small group of mental health professionals are still cap- tivated by the DID diagnosis, but the fad is over. In a combined 60-plus years of practice, we have observed a total of one, legiti- mate case of DID. Why did DSM-5 include an estimated commu- nity prevalence of 1.5 percent of DID based on an unidentified “small study?” We think that’s a good question.

In more recent years, diagnostic fads have focused on mental disorders in children. As we discuss in Chapter 15, The esti- mated prevalence of autism spectrum disorder increased by a factor of 50 between 1994 and today (Blumberg et al., 2013). That is not a typo. Fifty times as many children are said to suffer

from this disorder in 2013 as in 1994. Only slightly less dramatic is the increase in the diagnosis of bipolar disorders in children. Between 1994 and 2003, the diagnosis increased by a factor of 40 (Moreno et al., 2007). And as we discuss in Chapter 16, the children apparently did not suffer from bipolar disorder. In fact, DSM-5 created a whole new diagnosis to deal with this particu- lar fad.

We do not know what consequences today’s diagnostic fads will bring, good or bad. We do know how easy it is to get caught up in a fad, and how difficult it can be to say, “Wait a minute!” But science is a wait-a-minute approach to knowledge. Sometimes we need to slow down, admit what we do not know, and focus on trying to solve problems one small step at a time.

table 7.1 Sample Items from the Dissociative Experiences Questionnaire •   Some people find that sometimes they are listening to 

someone talk and they suddenly realize that they did not hear part or all of what was said.

•   Some people have the experience of being in a familiar  place but finding it strange and unfamiliar.

•   Some people have the experience of finding themselves  dressed in clothes that they don’t remember putting on.

•   Some people are told that they sometimes do not recognize  friends or family members.

•   Some people have the experience of feeling that their body  does not seem to belong to them.

•   Some people find that in one situation they may act so  differently compared with another situation that they feel almost as if they were two different people.

Source: Data from Bernstein, E.M., & Putnam, F.W. 1986. Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174(12), 727–735.

194 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

condition gave a new name (Spanos, Weekes, & Bertrand, 1985). In a subsequent study, hypnotized subjects also provided more “information” on exactly when in the past their alternate person- alities had first emerged (Spanos et al., 1986).

These findings certainly raise the caution that the “symp- toms” of DID can be induced by role playing and hypnosis (Lil- ienfeld et al., 1999). Moreover, accumulating evidence indicates that fantasy proneness and suggestibility play a key role in the development of dissociative disorders (Geisbrecht et al., 2008). Still, analogue studies cannot prove that role playing causes real cases of multiple personality (Gleaves, 1996).

Given the limited research, our inquiring skepticism causes us to reach some cautious conclusions. True dissociative disorders appear to be rare. Although some cases no doubt are misdiag- nosed, a much greater problem is the creation of the diagnosis in the minds of clinicians and clients (Piper & Mersky, 2004a, 2004b). At the same time, we remain curious about the dramatic cases and theoretical issues posed by accounts of dissociative disorders.

causes of Dissociative Disorders Little systematic research has been conducted on the cause of dissociative disorders. Thus, theory and outright speculation dominate this field.

PSychologIcAl FAcTorS There is little controversy that dissociative amnesia and fugue usually are precipitated by trauma. What about DID? Many case studies suggest that DID develops in response to trauma, particularly the trauma of child abuse. In fact, some researchers have compiled large numbers of case stud- ies from surveys of practitioners that support this view (Ross, 2009; see Table 7.2).

the psychologist and psychiatrist Martin Orne (1927–2000), an internationally recognized authority on hypnosis. Orne tested Bianchi by suggesting new symptoms to him. If Bianchi was faking, he might further the deception by developing the new symptoms. Orne suggested, for example, that if Bianchi really had DID, he should have a third personality. Sure enough, a third personality, Billy, “emerged” when Bianchi was hypno- tized (Orne, Dingers, & Orne, 1984). While hypnotized, Bi- anchi also followed Orne’s suggestion to hallucinate that his attorney was in the room. Bianchi actually shook hands with the supposed hallucination—a very unusual behavior for some- one under hypnosis. Orne concluded that Bianchi was indeed faking and actually suffered from antisocial personality disorder (see Chapter 9). Bianchi’s insanity defense failed, and he was found guilty of murder.

In testing his role theory, Spanos simulated procedures from the Bianchi case. In one study, undergraduate students played the role of the accused murderer and were randomly assigned to one of three conditions. In the “Bianchi” condition, the subjects were hypnotized, and the interviewer asked to communicate with their other part, just as Bianchi’s interviewer had asked. Sub- jects assigned to the second “hidden part” condition also were hypnotized, but this time it was suggested that hypnosis could get behind the “wall” that hid inner thoughts and feelings from awareness. In the final condition, there was no hypnosis, and sub- jects simply were told that personality included “walls” between hidden thoughts and feelings.

When subsequently asked, “Who are you?” in the mock mur- der case, 81 percent of the subjects in the Bianchi condition gave a name different from the one assigned to them in the role play, as did 70 percent of the subjects in the hidden part condition. In contrast, only 31 percent of the subjects in the no-hypnosis

table 7.2 Correlates of Dissociative Identity Disorder in Two Surveys of Clinicians

ross1 Putnam2

Item N 5 236 N 5 100

Average age 30.8 35.8

Percentage of females 87.7% 92.0%

Average years of treatment before diagnosis 6.7 6.8

Average number of personalities 15.7 13.3

Opposite-sex personality present 62.6% 53.0%

Amnesia between personalities 94.9% 98.0%

Past suicide attempt 72.0% 71.0%

History of child physical abuse 74.9% 75.0%

History of child sexual abuse 79.2% 83.9%

1Based on data from C. A. Ross, G. R. Norton, and K. Wozney. 1989. Multiple Personality Disorder: An Analysis of 236 Cases. Canadian Journal of Psychiatry; 34: 413–418. 2Based on data from F. W. Putnam, J. J. Curoff, et al. 1986. The Clinical Phenomenology of Multiple Personality Disorder: Review of 100 Recent Cases. Journal of Clinical Psychiatry; 47: 285–293.

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 195

Even if trauma contributes to dissociative disorders—and we are skeptical about trauma and DID, it clearly is not a sufficient cause. As we saw with ASD and PTSD, the vast majority of peo- ple who experience trauma do not develop a dissociative disorder. Thus, other factors must contribute to their development.

BIologIcAl FAcTorS Little research addresses the contri- bution of biological factors to dissociative disorders (Kihlstrom, 2005). A recent proposal suggests that a fragmented sleep-wake cycle helps explain dissociative symptoms (van der Kloet et al., 2012). In support of this novel view, research finds a relation between sleep disturbance and dissociation, experimental depri- vation of sleep increases dissociative experiences, and improved sleep decreases dissociation (Lynn et al., 2012; van der Kloet et al., 2012).

SocIAl FAcTorS Perhaps the most important theory about social contributions to dissociative disorders is that they are caused by iatrogenesis, the manufacture of a disorder by its treatment. Mersky (1992) reviewed classic case studies of DID and concluded that many “cases” were created by the expectations of therapists. Mersky does not doubt the pain experienced by the patients in these cases. He argues, however, that the patients developed multiple personalities in response to their therapists’

When interpreting these findings, however, you should note that studies of the long-term consequences of child physical or sexual abuse find little evidence of dissociation or, indeed, of any consistent forms of psychopathology (Clancy, 2010; Emery & Laumann-Billings, 1998; Rind, Tromovitch, & Bauserman, 1998). And case studies are based on patients’ memories and clinicians’ evaluations. They are not objective assessments of the past. Researchers have many concerns about the validity of such retrospective reports—evaluations of the past from the vantage point of the present (see Research Methods). Memories may be selectively recalled, distorted, or even created to conform to a cli- nician’s expectations (Geisbrecht et al., 2008; Kihlstrom, 2005).

If trauma is involved, how might it lead to the development of multiple personalities? One theory invokes state-dependent learning, a process where learning that takes place in one state of affect or consciousness is best recalled in the same state of af- fect or consciousness (Bower, 1990). For example, when you are sad rather than happy, you more easily remember what happened when you were sad in the past. By extension, experiences that oc- cur during a dissociated state may be most easily recalled within the same state of consciousness. Perhaps through the repeated experience of trauma, dissociation, and state-dependent learning, more complete and autonomous memories develop—ultimately leading to independent personalities (Braun, 1989).

rESEArCh methods

Retrospective Reports: Remembering the Past

Psychologists have long been skeptical about the accuracy of people’s reports about the past. The concern is about the reliability and validity of retrospective reports— current recollections of past experiences, for example, events that oc- curred during childhood. Problems with retrospective reports are one of several reasons why investigators prefer prospective, longitudinal studies over retrospective research designs (see the Research Methods box in Chapter 8).

Concerns about retrospective reports focus on three particular issues. First, normal memory often is inaccurate, particularly memory for events that occurred long ago and early in life. Second, memories of people with emotional problems may be particularly unreliable. Third, abnormal behavior may system- atically bias memory; for example, memory processes may be “mood congruent.” Depressed people may tend to remember sad experiences, anxious people may better recall fearful events, and so on.

Brewin, Andrews, and Gotlib (1993) revisited many of these con- cerns, but concluded that retrospective memories may be less flawed than some have suggested. The reviewers agreed that retrospective reports are often inaccurate. For example, only moderate correlations are found between children’s and parents’

reports about their past relationships, and, on average, children report more negative memories. At the same time, agreement between parents and children increases to an acceptable level for reports of specific, factual aspects of the past. Thus, memory for specific, important events in the family may be fairly reliable and valid, but people may “rewrite” their histories with regard to more global and subjective experiences.

Brewin and colleagues (1993) also questioned the blanket as- sumption that psychopathology impairs memory. They found many flaws in research that supposedly demonstrated memory impairments for various psychological problems and concluded that, except for serious mental illness, there is no evidence for memory impairments associated with anxiety or depression. In particular, depressed people do not erroneously recall more than their share of negative events about the past.

Brewin and colleagues (1993) urge that retrospective reports should not be dismissed out of hand. Psychologists have many reasons to prefer prospective, longitudinal research over ret- rospective methods, but longitudinal research is expensive. Retrospective reports of specific events may be sufficiently reli- able and valid to justify using them as an initial, less-expensive research method.

196 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

The ultimate goal in treating DID is not to have one per- sonality triumph over the others. Rather, the objective is to inte- grate the different personalities into a whole (Coons & Bowman, 2001). Integration is not unlike the task we all face in reconciling our different roles in life into a coherent sense of self. Dallae, for example, needed to reconcile her role as a daughter, including her parents’ expectations, together with her role as an independent young woman with her own desires, abilities, and acculturation experiences.

At this time, no systematic research has been conducted on the effectiveness of any treatment for dissociative disorders, let alone on the comparison of alternative treatments (Kihlstrom, 2005; Maldonado, Butler, & Spiegel, 2001). Antianxiety, antide- pressant, and antipsychotic medications sometimes are used, but at best these medications reduce distress. They do not cure the disorder. Advances in treatment await a better understanding of the disorders and, more generally, of conscious and unconscious mental processes. In the meantime, you should view treatments championed for dissociative disorders—and the accuracy of the diagnosis itself—with a healthy dose of skepticism.

Somatic Symptom Disorders In addition to dissociative disorders, hysteria included conversion disorder, problems with motor or sensory function occurring in the absence of a known physical illness. “Hysterical blindness” and “hysterical paralysis” are two old names and examples of these problems, symptoms that greatly influenced Freud’s and Janet’s theorizing, and perhaps were more common during their lifetimes. We consider conversion disorder in the same chapter with disso- ciative disorders because of their historical connection and because conversion disorder appears to involve dissociation. However, DSM-5 now treats conversion disorder as a somatic symptom disorders—problems where physical symptoms are prominent and are accompanied by impairing psychological distress. We dis- cuss several somatic symptom disorders in this section, and con- tinue with the topic in the next chapter on stress and health.

Symptoms of Somatic Symptom Disorders All somatic symptom disorders discussed in this chapter involve complaints about physical symptoms that create psychological dis- tress either out of proportion to actual physical problems or in the absence of a diagnosable physical illness. The symptoms are not feigned or intentionally exaggerated. The physical problem is very real in the mind, though evidently not the body, of the sufferer.

The physical symptoms can take a number of forms. In dra- matic cases, the symptom involves substantial impairment, par- ticularly in the sensory or muscular system. The patient will be unable to see, for example, or will report paralysis in one arm. In other cases, patients experience one or perhaps several more mi- nor physical symptoms such as pain, upset stomach, dizziness, or some vague complaint that is misinterpreted as a sign of a serious

leading questions. Like Spanos (1994), Mersky argues that DID is a social role. Because of their susceptibility to suggestion, per- haps highly hypnotizable people are especially likely to suffer from iatrogenic effects (Kihlstrom, Glisky, & Angiulo, 1994).

We believe that iatrogenesis is the explanation for the explo- sion of DID cases diagnosed in the United States, especially in the wake of Sybil’s popularity. However, we also believe that DID is a real if rare problem. DID has been diagnosed in the general population in Turkey, where there is no public awareness of the disorder (Akyuz et al., 1999). And suggestibility alone does not appear to explain dissociation (Dalenberg et al., 2012).

Treatment of Dissociative Disorders Dating from the time of Janet and Freud, most treatments of dis- sociative disorders have focused on uncovering and recounting traumatic memories. Presumably, the need for dissociation disap- pears if the trauma can be expressed and accepted (Horevitz & Loewenstein, 1994). Many clinicians use hypnosis to help pa- tients explore and relive traumatic events. However, no research supports the effectiveness of either abreaction, the emotional re- living of a past traumatic experiences, or hypnosis as a treatment for dissociative disorders (Horevitz & Loewenstein, 1994). Skep- tics worry, in fact, that hypnosis may create dissociative symp- toms or false memories of abuse (Casey, 2001).

Shirley Mason Ardell, the real “Sybil.” Her case spurred an explosion in the diagnosis of dissociative identity disorder, and in the number of diagnosed “alters,” but actual therapy tapes suggest that her therapist may have implanted Sybil’s 16 personalities.

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 197

converSIon DISorDer The dramatic symptoms of con- version disorder include altered motor or sensory function that typically mimic neurological problems with one exception: Conversion symptoms make no anatomic sense. A patient may complain about anesthesia (or pain) in a way that does not cor- respond with the innervation of the body. In some facial anesthe- sias, for example, numbness ends at the middle of the face. But the nerves involved in sensation do not divide the face into equal halves (see Figure 7.4).

The term conversion disorder accurately conveys the central assumption of the diagnosis—the idea that psychological con- flicts are converted into physical symptoms. This idea captivated Charcot, Freud, and Janet and led them to develop theories about dissociation and unconscious mental processes. The following case from Janet’s writings illustrates his view of hysteria.

Janet’s Hysterical Patient A girl of 19 years of age suffered, at the time of her monthly pe- riod, convulsive and delirious attacks which lasted several days. Menstruation began normally, but a few hours after the com- mencement of the flow the patient complained of feeling very cold and had a characteristic shivering; menstruation was imme- diately arrested and delirium ensued. In the interval of these at- tacks the patient had paroxysms of terror with the hallucination of blood spreading out before her and also showed various per- manent stigmata, among others, anesthesia of the left side of the face with amaurosis of the left eye.

During a careful study of this patient’s history, and particu- larly of the memories she had conserved of various experiences of her life, certain pertinent facts were ascertained. At the age of 13 she had attempted to arrest menstruation by plunging into a tub of cold water with resulting shivering and delirium; menstrua- tion was immediately arrested and did not recur for several years; when it did reappear the disturbance I have just cited took place. Later on she had been terrified by seeing an old woman fall on the stairs and deluge the steps with her blood. At another time,

illness like cancer. Anxiety persists despite negative medical tests and clear reassurance by a physician.

unneceSSAry meDIcAl TreATmenT People with somatic symptom disorders typically do not bring their problems to the attention of a mental health professional. Instead, they repeatedly consult their physicians about their “physical” problems (Bass, Peveler, & House, 2001; Looper & Kirmayer, 2002). This often leads to unnecessary medical treatment. In one study, patients with one of these somatic symptom disorders had seen a health- care provider more than six times, on average, during the previ- ous six months. One-fourth of patients had been hospitalized in the past year, compared with 12 percent of the general popula- tion (Swartz et al., 1987).

Patients often complain about realistic physical symptoms that are difficult to evaluate objectively. Thus, physicians fre- quently do not recognize the psychological nature of the patients’ problems, and they sometimes perform unnecessary medical pro- cedures. These patients have surgery twice as often as people in the general population (Zoccolillo & Cloninger, 1986). In fact, some common surgical procedures are performed with startling frequency on patients with these somatic symptom disorders. One research group concluded that, after discounting cancer surgeries, 27 percent of women undergoing a hysterectomy suffered from this psychological problem (Martin, Roberts, & Clayton, 1980).

Such data are distressing not only because of the risk to the patient but also because of the costs of unnecessary medical treatment. Estimates indicate that anywhere from 20 percent to 84 percent of patients who consult physicians do so for problems for which no organic cause can be found (Miller & Swartz, 1990). Such visits may account for as much as half of all ambulatory healthcare costs (Kellner, 1985). A variety of emotional problems can motivate people to consult their physicians, including the ex- perience of trauma (Green et al., 1997). For example, patients with one of these somatic symptom disorders are three times more likely to consult physicians than are depressed patients (Morrison & Herbstein, 1988; Zoccolillo & Cloninger, 1986). Health care expenditures are nine times the average annual per capita cost of medical treatment (Smith, Monson, & Ray, 1986).

Diagnosis of Somatic Symptom Disorders DSM-5 lists five major somatic symptom disorders: (1) conver- sion disorder, (2) somatic symptom disorder, (3) illness anxiety disorder, (4) factitious disorder, and (5) psychological factors af- fecting other medical conditions. The last diagnosis is different. The physical illness is undoubtedly real, and emotional reactions surrounding the illness are not exaggerated. Instead, psycho- logical factors affecting other medical conditions are diagnosed for stress-involved physical illnesses (see Chapter 8). We briefly describe the other four somatic symptom disorders along with body dysmorphic disorder, which DSM-5 decided to list with obsessive–compulsive disorders (see Chapter 6).

figure 7.4 conversion disorder symptoms may make no anatomical sense. As illustrated in this figure, pain insensitivity may be limited to one side of the face, but the nerves involved in pain sensation do not divide the face neatly in half. Source: Adapted from D. M. Kaufman, 1985, Clinical Neurology for Psychiatrists, 2nd ed., p. 28. Copyright © 2007 Elsevier. Reprinted by permission.

198 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

belle indifference as defining characteristics of somatic symptom disorder, they are found in only a minority of cases (Brown, 2004; Lipowski, 1988).

In contrast to stereotypes, somatic symptom disorder is not more common among the aged, who consult healthcare profes- sionals frequently because of chronic and real physical illnesses (National Institute of Mental Health, 1990). In fact, somatic symptom disorder often begins in adolescence. The problem sometimes has been called Briquet’s syndrome, in recognition of the French physician Pierre Briquet, who was among the first to call attention to the multiple somatic complaints found in some “hysterias” (National Institute of Mental Health, 1990).

IllneSS AnxIeTy DISorDer Illness anxiety disorder is characterized by a fear or belief that one is suffering from a physical illness, but physical symptoms are either absent or mi- nor. Aspects of this disorder are familiar to you. Formerly called hypochondriasis, the term was changed in DSM-5, since it had be- come a demeaning part of everyday language. We all worry about our health, and even unrealistic worries sometimes are normal. For example, medical students often fear that they have contracted each new disease they encounter. We should warn you: Many stu- dents in abnormal psychology suffer from a similar problem.

Illness anxiety disorder is much more serious than these normal and fleeting worries. The disorder is preoccupying, endur- ing, and often leads to substantial impairment in life functioning (see “DSM-5: Illness Anxiety Disorder”). Even a thorough medi- cal evaluation does not alleviate fears. The person still worries that the illness may be emerging or that a test was overlooked. But the patient is not delusional. Someone may worry excessively about contracting AIDS, for example, and repeatedly go for blood tests. When faced with negative results, the person does not delusionally believe that he actually has contracted the illness. Instead, he per- sistently worries that the test was wrong or was taken too soon to detect the disease. Watch the Video Henry: Illness Anxiety Disorder on MyPsychLab

when she was about 9 years old, she had been obliged to sleep with a child whose face, on the left side, was covered with scabs, and during the whole night she had experienced a feeling of in- tense disgust and horror (Janet, 1914/1915, pp. 3–4).

This case describes symptoms that are consistent with conversion disorder. The numbness on the left side of the face and loss of vision (amaurosis) are clear examples of conversion symptoms. At the same time, we wonder about other aspects of this classic case. The frightening hallucinations of blood might suggest another diagnosis, perhaps psychotic depression or schizophrenia. Differential diagnosis was poor during the time of Charcot, Janet, and Freud, and we think that this might explain why conversion disorders were thought to be prevalent then but are rare today (Shorter, 1992). Many problems would be accu- rately identified today probably were misdiagnosed as conversion disorders a century ago. Concerns about misdiagnosing unde- tected but real physical problems as being “psychological” still apply to the diagnosis today, as we discuss shortly, In fact, this is one reason why these problems were relabeled “somatic symptom disorders” (Stone et al., 2010).

SomATIc SymPTom DISorDer Somatic symptom disorder (singular) is one of several somatic symptom disorders (plural) and is characterized by at least one and usually several somatic complaints accompanied by excessive concern about the symp- toms. Chronic pain may or may not be a part of the presenta- tion. Similar to what was formerly called “somatization disorder,” patients with somatic symptom disorder sometimes present their symptoms in a histrionic manner—a vague but dramatic, self- centered, and seductive style. Patients also may exhibit la belle indifference (the beautiful indifference), a flippant lack of con- cern about their symptoms. For example, a patient may list a long series of somatic complaints in an offhanded and cheerful manner. Although some experts view a histrionic style and la

criteria for Illness Anxiety Disorder

A. Preoccupation with having or acquiring a serious illness.

B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.

c. There is a high level of anxiety about health, and the indi- vidual is easily alarmed about personal health status.

D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness)

or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).

e. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.

F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom dis- order, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 199

and often painful medical procedures in order to garner attention from health care professionals. A rare, repetitive pattern of facti- tious disorder is sometimes called Munchausen syndrome, named after Baron Karl Friedrich Hieronymus von Munchausen, an eighteenth-century writer known for his tendency to embellish the details of his life.

Frequency of Somatic Symptom Disorders No one knows how prevalent conversion disorders were during the time of Charcot, Janet, and Freud, but the literature of the period suggests that they were common (Shorter, 1992). Today, conversion disorders are rare, perhaps as infrequent as 50 cases per 100,000 population (Akagi & House, 2001). Ironically, the unusual disorders treated by Freud and Janet have been less en- during than the theories developed to explain them. The lower prevalence today may be a result of improved diagnostic prac- tices—cases now are correctly diagnosed as real physical or psychological illnesses, or perhaps of Western society’s greater acceptance of the expression of feelings (Shorter, 1992). A very different—and controversial—viewpoint is that conversion disorders are prevalent today, but they take the form of con- ditions like chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and similar puzzling maladies (Johnson, 2008; Showalter, 1997).

Other somatic symptom disorders are more common. DSM-5 estimates that about 5 percent to 7 percent of the popu- lation suffers from somatic symptom disorder, while 1 percent to 10 percent suffer from illness anxiety disorder. The estimates are imprecise, because DSM-5 changed the diagnostic crite- ria, making past research difficult to apply. One study found a 0.7 percent prevalence of body dysmorphic disorder (Otto et al., 2001). The prevalence of factitious disorder and malingering are impossible to pinpoint, of course, because the problems involve deliberate deception.

BoDy DySmorPhIc DISorDer Body dysmorphic disorder, now considered an obsessive-compulsive disorder, is similar to somatic symptom disorders, because the problem involves pre- occupation with some imagined defect in appearance. The pre- occupation typically focuses on some facial feature, such as the nose or mouth, and in some cases may lead to repeated visits to a plastic surgeon. Preoccupation with the body part far exceeds normal worries about physical imperfections. The endless worry causes significant distress, and in extreme cases, it may interfere with work or social relationships.

U.S. researchers are only beginning to study body dysmor- phic disorder (Phillips et al., 2010). The problem has received somewhat more attention in Japan and Korea, where it is classi- fied as a type of social phobia (Phillips et al., 2010). The follow- ing brief case history illustrates this problem.

Body Dysmorphic Disorder A 28-year-old single white man became preoccupied at the age of 18 with his minimally thinning hair. Despite reassurance from others that his hair loss was not noticeable, he worried about it for hours a day, becoming “deeply depressed,” socially with- drawn, and unable to attend classes or do his schoolwork. Although he could acknowledge the excessiveness of his preoc- cupation, he was unable to stop it. He saw four dermatologists but was not comforted by their reassurances that his hair loss was minor and that treatment was unnecessary. The patient’s preoccupation and subsequent depression have persisted for 10 years and have continued to interfere with his social life and work, to the extent that he avoids most social events and has been able to work only part-time as a baker. He only recently sought psychiatric referral, at the insistence of his girlfriend, who said his symptoms were ruining their relationship (Phillips, 1991, pp. 1138–1139).

mAlIngerIng AnD FAcTITIouS DISorDer Somatic symp- tom disorders are real psychological problems, even though the physical symptoms are not always real. This distinguishes them from malingering, pretending to have a physical illness in order to achieve some external gain, such as a disability payment. Be- cause there is no objective test for somatic symptom disorders, detecting malingering is extremely difficult. Besides searching for an obvious reason for feigning an illness, one clue to malingering can be when a patient presents symptoms that are more, not less, dramatic than is typical.

A related diagnostic concern is factitious disorder, a feigned condition that, unlike malingering, is motivated primarily by a desire to assume the sick role rather than by a desire for exter- nal gain. DSM-5 lists factitious disorder as one of the somatic symptom disorders. People with factitious disorder pretend to be ill or make themselves appear to be ill, for example, by taking drugs to produce a rapid heart rate. They will undergo extensive

Children often describe their anxiety in somatic terms, “My stomach hurts!” Cultural and historical differences in somatoform disorders sometimes are attributed to a similar lack of insight into emotion.

200 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

but they often are found in different members of the same family (Lilienfeld, 1992). Because antisocial personality disorder is far more common among men, while somatic symptom disorder has the opposite pattern, some have speculated that the two problems are flip sides of the same coin. Antisocial personality disorder may be the male expression of high negative emotion and the absence of inhibition, whereas somatic symptom disorder is the female expression of the same characteristics (Lilienfeld, 1992).

causes of Somatic Symptom Disorders Despite their historical and medical significance, surprisingly lit- tle systematic research has been conducted on somatic symptom disorders. We integrate emerging findings with some theoretical considerations in the context of the biopsychosocial model.

BIologIcAl FAcTorS—The PerIlS oF DIAgnoSIS By excluSIon An obvious—and potentially critical—biological consideration in somatic symptom disorders is the possibility of misdiagnosis. A patient may be incorrectly diagnosed as suffering from a psychological problem when, in fact, he or she actually has a real physical illness, one that is undetected or is perhaps unknown. The diagnosis of a conversion disorder requires that there is no known organic cause of the symptom. This is very different from the positive identification of a psychological cause of the symptom.

The identification of somatic symptom disorders often in- volves a process called diagnosis by exclusion. The physical com- plaint is assumed to be a psychological disorder after various known physical causes are ruled out. Indeed, experts increas- ingly refer to somatic symptom disorders as medically unex- plained syndromes (Johnson, 2008; Smith et al., 2005). The possibility always remains that an incipient somatic disease has

genDer, SeS, AnD culTure Somatic symptom disorders are more common among women than men (Swartz et al., 1990). Why women? Some feminist writers attribute women’s hysteria during the time of Freud and Janet to the sexual repression of the Victorian era. Today’s disproportionate prevalence among women often is blamed on widespread sexual abuse. Feminist Elaine Showalter (1997) criticizes both of these views. Instead, she ar- gues, “Women still suffer from hysterical symptoms not because we are essentially irrational or because we’re all victims of abuse but because, like men, we are human beings who will convert feelings into symptoms when we are unable to speak” (p. 207).

Socioeconomic status and culture also are thought to con- tribute to the frequency of somatic symptom disorders. In the United States, they are more common among lower socioeco- nomic groups, people with less than a high school education, and African Americans. The prevalence also is considerably higher in Puerto Rico than on the U.S. mainland (Canino et al., 1987). However, expected differences between industrialized and nonin- dustrialized countries were not found in a study sponsored by the World Health Organization. The one notable cultural difference was the high prevalence of somatization in Latin America (Gureje et al., 1997). Some speculate that this is due to a Latin view of emotional expression as a sign of weakness, while others hypoth- esize that it is due to the stigma associated with mental illness.

In addition to affecting prevalence, culture can influence when and how somatic symptoms are experienced. An example is hwa-byung, a Korean folk syndrome that is attributed to unex- pressed anger. (The open expression of anger is frowned upon in Korea.) The symptoms of hwa-byung include fatigue, insomnia, indigestion, and various aches and pains.

comorBIDITy Somatic symptom disorders typically occur with other psychological problems, particularly depression and anxiety (Creed & Barsky, 2004; Otto et al., 2001; Smith et al., 2005). The link with depression has several possible explanations. Either condition may cause the other, or both could be caused by a third variable, such as life stress. One possibility that primary care physicians must consider carefully is that some patients may express depression indirectly through their somatic complaints (Lipowski, 1988).

There also are several possible explanations for the comor- bidity with anxiety, including the fact that anxiety often is expe- rienced physically and may be misreported in terms of physical symptoms (upset stomach, dizziness, weakness, sweating, dry mouth). A particular concern is the accurate, differential diagno- sis of panic disorder. Some symptoms of panic, such as dizziness, numbness, and fears about dying, may be dismissed by physi- cians, or misdiagnosed as either illness anxiety disorder or somatic symptom disorder (Lipowski, 1988).

Finally, somatic symptom disorder has frequently been linked with antisocial personality disorder, a lifelong pattern of irrespon- sible behavior that involves habitual violations of social rules. The two disorders do not typically co-occur in the same individual,

Diagnosis by exclusion is like identifying a criminal by ruling out other suspects. “It isn’t the guy in the flowered shirt, he didn’t have a mustache, and the two guys on the left are too stocky. It must be the guy on the right.” But the real criminal might not be in the lineup, and the real disease might go undetected when using diagnosis by exclusion.

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 201

PSychologIcAl FAcTorS—ImAgIneD or reAl TrAumA Initially, both Freud and Janet assumed that conver- sion disorders were caused by a trauma, particularly sexual abuse. However, Freud later questioned the accuracy of his patients’ re- ports. Instead, he decided that their sexual memories were fanta- sized, not real. This led him to develop his theory of childhood sexuality (Freud, 1924/1962). He came to view dissociation as protecting people from unacceptable sexual impulses, not from intolerable memories (Freud, 1924/1962). Sadly, we now know that childhood sexual abuse is all too common. Freud’s initial po- sition may have been the accurate one.

Somatization at least sometimes can be triggered by trau- matic stress. A study of 358 people who worked in the mortuary during the first Gulf War found an increase in somatic symptoms as a result of the experience. Symptoms included faintness, pain in the chest, nausea, trouble breathing, hot or cold spells, numb- ness, and feeling weak. Importantly, the before-to-after increase occurred more among workers with greater exposure to death. Symptoms increased more among workers who actually handled bodies compared to those who only observed bodies. Symptoms did not increase among workers with no exposure (McCarroll et al., 2002). Likely contributors to why trauma leads to soma- tization include the somatic consequences of stress, an increased awareness of one’s own body, and the expression of psychological distress through somatic complaints.

Freud also suggested that the primary gain of hysterical symptoms was the expression of unconscious conflicts. He also indicated that conversion could produce secondary gain, for ex- ample, avoiding work or gaining attention. This latter view has more support than Freud’s ideas about primary gain, although cognitive behavior therapists call this reinforcement. In addition to positive reinforcement (extra attention) or negative reinforce- ment (avoidance of work), learning the sick role through modeling may contribute to somatic symptom disorders (Lipowski, 1988). Cognitive factors also may play a role, especially (1) a tendency to amplify somatic symptoms (Brown, 2004; Kirmayer, Robbins, & Paris, 1994); (2) alexithymia—a deficit in one’s capacity to recog- nize and express the emotions signaled by physiological arousal (Bankier, Aigner, & Bach, 2001); (3) the misattribution of nor- mal somatic symptoms (Brown, 2004; Rief, Hiller, & Margraf, 1998); and (4) memory biases (Pauli & Alpers, 2002). Figure 7.5 summarizes how these and other factors may contribute to the development of somatic symptom disorders.

SocIAl FAcTorS A widely held social theory of somatic symp- tom disorders argues that when people in certain cultures expe- rience psychological distress, they describe and experience their emotions as physical symptoms. Why? The theory assumes that some cultures do not teach or allow open emotional expression. A simple analogy for this theory is a child who complains about an upset stomach, not fear of failure, before giving a piano recital. Presumably, increasing psychological awareness explains both a decline in somatic symptom disorders over time and a lower

been overlooked. Some of the problems with diagnosis by exclu- sion can be appreciated by way of analogy. Consider the dif- ference in certainty between two police lineups, one in which a victim positively identifies a criminal—“That’s him!”—versus a second where the identification is made by ruling out alter- natives—“It isn’t him or him or him, so I guess it must be that one.”

The possibility of misdiagnosis is more than a theoretical concern. Follow-up studies of patients diagnosed as suffering from conversion disorders show that somatic illnesses are later detected in some cases (Escobar et al., in press; Kroenke et al., 2007). Typically, a neurological disease such as epilepsy or mul- tiple sclerosis is the eventual diagnosis. In one classic study, a quarter of patients diagnosed as having a conversion symptom later developed a neurological disease (Slater, 1965). Fortunately, recent research has found a much smaller percentage (5 percent or less) of undetected physical illnesses when following up cases of somatic symptom disorders several years later (Crimlisk et al., 1998; Schuepbach, Adler, & Sabbioni, 2002). We attribute the new findings to the improved detection of real physical illnesses, and again wonder how many of the hysterias treated by Charcot, Freud, and Janet would be diagnosed correctly as real physical conditions today.

Consider the case presented in the November 11, 2009, Diagnosis column of the New York Times Magazine. A 46- year-old woman suffered from a variety of mysterious physical symptoms. Over the years, she received multiple diagnoses, including that her problems were psychological. At the age of 23, she developed intermittent attacks of abdominal pain, fever, and vomiting that continued to the present day. Recently, her hands and feet had become numb, so much so that she could barely hold a pen or walk without stumbling. The woman was hospitalized dozens of times and had 13 surgeries, including the removal of her appen- dix, ovaries, and most of her colon.

Classic conversion disorder? Janet may have thought so, and at least some contemporary physicians reached that conclusion using diagnosis by exclusion. Yet, a neurologist finally diagnosed the very rare condition, porphyria, a genetically transmitted dis- ease of the nervous system that affects red blood cells. Porphyria causes multiple physical and mental symptoms, sometimes in- cluding hallucinations and paranoia. The disease cannot be cured, but it at least can be understood and managed.

To avoid problems with diagnosis by exclusion, some experts recommend limiting the diagnosis of functional neurological symp- toms (a proposed replacement term for conversion disorders) to cases where neurological tests clearly show inconsistent results (Friedman & LaFrance, 2010). An example would be when a pa- tient has a “seizure,” but an EEG indicates normal brain activity (APA, 2010). Perhaps the use of such a more circumspect defini- tion of conversion disorder will help us to better understand how psychological stress can cause physical symptoms—and avoid telling patients with real physical illnesses that the problem is “all in your head.”

202 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

on any treatment. While research is still limited, accumulating evidence indicates that cognitive behavior therapy can reduce physical symptoms in somatic symptom disorder (Woolfolk, Allen, & Tiu, 2007), illness anxiety disorder (Clark et al., 1998; McManus et al., 2012), and body dysmorphic disorder (Rosen, Reiter, & Orosan, 1995).

The most extensive studies focus on pain management. Cog- nitive behavioral approaches to chronic pain alter contingencies that reward pain behavior and the sick role. The goal is to reward successful coping and life adaptation instead (Kroenke, 2007). Cognitive behavior therapy also uses cognitive restructuring to address the emotional and cognitive components of pain. Re- search demonstrates the effectiveness of both approaches in treat- ing chronic lower back pain (Blanchard, 1994).

Antidepressants also may be helpful in treating somatic symp- tom disorders, although less research has been conducted on their effectiveness (Kroenke, 2007). SSRIs produce more improvement in comparison to placebo for body dysmorphic disorder (Phil- lips, Albertini, & Rasmussen, 2002) and pain (Fishbain et al., 1998). Both medication and cognitive behavior therapy may be

prevalence in the West compared to other cultures today (Shorter, 1992). As noted earlier, however, unusual physical illnesses may have been misdiagnosed 100 years ago, and the disorders do not appear to be more prevalent in nonindustrialized than industri- alized countries today. In fact, many suggest that contemporary, Western psychological “awareness” has become more than a little overdone. The Western focus on emotion may have moved be- yond “open” into the realm of “obsessed.”

Treatment of Somatic Symptom Disorders Charcot, Janet, and Freud encouraged their patients to recall and recount psychologically painful events as a way of treating con- version disorders. In the century or more since they refined their techniques, however, no systematic research was conducted on any cathartic therapies for conversion disorders, or for that matter,

Medical illness, physiological perturbations

Psychiatric disorder, stress, trauma

Attention to body

Attribution of sensations

to illness

Illness worry, catastrophizing demoralization

Communication of distress

and help-seeking

Avoidance and disability

Physiological disturbance

Emotional arousal

Social response

figure 7.5 Minor physical symptoms may develop into a somatoform disorder when combined with emotional arousal, excessive attention to physical  symptoms, misattributions, and other psychological tendencies and social reactions. Source: Copyright © 2002, American Psychological Association.

“Anna O,” a pseudonym for Bertha Pappenheim and the subject of a famous case study by Sigmund Freud, actually was treated by Josef Breuer. Anna O suffered from multiple “conversion” symptoms and was “successfully” treated with free association. Historical records indicate that treatment failed and suggest a neurological basis for her symptoms.

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 203

This can be difficult. The absence of a clear physical problem can frustrate primary care physicians, who may be unsympathetic toward “hypochondriacs” when they have so many patients with “real” problems. Not surprisingly, such reactions weaken the physician–patient relationship, and this can intensify the prob- lem. In fact, the major recommendation for the medical manage- ment of patients with somatic symptom disorders is to establish a strong and consistent physician–patient relationship. Physicians are urged to schedule routine appointments with these patients every month or two and to conduct brief medical exams during this time (Allen et al., 2002). This approach not only provides consistent emotional support and medical reassurance but also helps to reduce unnecessary medical care. Patients who feel misunderstood are likely to recruit a new, more understanding physician ( Allen et al., 2002). On the other hand, a physician who knows the patient can recognize the psychological origin of the physical complaints and order fewer unnecessary medical tests or treatments.

effective, in part, because the treatments alleviate the depression and anxiety that often are comorbid with somatic symptom dis- orders (Looper & Kirmayer, 2002; Simon, 2002). However, a re- cent study of mindfulness-based cognitive therapy found that the approach reduced illness anxiety beyond usual treatment without reducing comorbid anxiety or depression. Of interest, the mind- fulness approach encourages more, not less, awareness of physi- cal symptoms. Consistent with its roots in Eastern meditation, however, mindfulness encourages acceptance of symptoms as pass- ing events, a contrast to Western approach to control and change them (McManus et al., 2012).

One reason for the limited psychological research is that pri- mary care physicians treat most somatic symptom disorders (Bass et al., 2001). Patients typically consult physicians about their ail- ments, and they often insist that their problems are physical despite negative test results. Such patients are likely to refuse a referral to a mental health professional. As a result, primary care physicians often must learn how to manage the problems in a medical setting.

getting hELP

The disorders discussed in this chapter are fascinating, and the controversies about them are intellectually exciting—unless you or someone you know is suffering from PTSD or a dissociative or somatic symptom disorder. In this case, the unusual symptoms can be extremely frightening, the lack of ac- ceptance can be isolating, and the controversy surrounding the disorders can seem callous.

The controversies and limited scientific information make it dif- ficult to make clear recommendations for getting help. However, you can review the treatment sections of the three disorders to get some specifics on the best approaches based on current re- search. These treatments generally involve some type of cogni- tive behavior therapy and/or antidepressant medication.

We also can readily offer a strong suggestion: If you have been the victim of trauma, for example, rape, abuse, or disaster, or a victim or witness of some other form of violence, talk to some- one about it. You may find it difficult to trust anyone, but trying to “forget about it” is exactly the wrong thing to do. Confront- ing fear, embarrassment, or others’ lack of understanding is far better than keeping it all inside. If you are not willing to consider therapy, start by confiding in a friend, a family member, even a stranger.

We are particularly concerned about the trauma of rape, includ- ing acquaintance rape, an all-too-frequent occurrence among college students. If you or someone you know has been raped, the first step may be to get to a hospital emergency room or to call the police. You also may want to contact a rape crisis center

in your area. The Rape Abuse and Incest Network National hotline, (800)-656-4673, can provide you with the telephone number of the rape crisis center closest to you. You also may want to visit its Web site: http://www.rainn.org. A good self-help book on rape is Free of the Shadows: Recovering from Sexual Violence, by Caren Adams and Jennifer Fay.

There are many other resources available for victims of rape, disasters, and other traumas. If you are surfing the Web for infor- mation, we suggest that you begin your Internet exploration with the National Institute of Mental Health (NIMH). You will find much helpful information there, as well as links to other useful websites.

Another reason why we recommend that you begin with the NIMH website is that you need to be extremely cautious about information on PTSD and dissociative and somatic symptom disorders. The controversies discussed in this chapter are not just theoretical ones. There are many self-help resources—and professionals—who claim that one side or the other of a given controversy is fact, not theory or opinion. We urge you to be wary if a professional or resource fails to acknowledge the uncer- tain state of scientific information and the range of opinion about such things as the long-term consequences of childhood trauma, the prevalence of multiple personality disorder, or the nature of recovered memories. A dramatic illustration of the havoc that can be created by those who are supposed to help can be found in the book, Remembering Satan, Lawrence Wright’s journalistic account of the consequences of one episode of false “recovered memories” of satanic ritual abuse.

204 CHAPTER 7 acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders

Dissociation is the disruption of the normally integrated mental processes involved in memory or consciousness.

Traumatic stress is an event that involves actual or threatened death, serious injury, or sexual violence to self, or witness- ing others experience trauma, learning that loved ones have been traumatized, or repeatedly being exposed to details of trauma.

Acute stress disorder (ASD) is a reaction to trauma that lasts less than one month and is characterized by symptoms of (1) intrusive reexperiencing, (2) avoidance of reminders of the trauma, (3) increased arousal or reactivity, (4) negative mood or thoughts, and often (5) dissociation.

Posttraumatic stress disorder (PTSD) is characterized by very similar symptoms as ASD, even though DSM-5 lists them some- what differently, but the symptoms either last for longer than one month or have a delayed onset.

Trauma is distressingly common and often leads to PTSD, especially rape for women and combat exposure for men.

Trauma is the central cause of PTSD, but other factors contrib- ute to its development, including level of exposure, social sup- port, genetics, pretrauma personality, avoidance, and emotional processing.

Targeted and naturalistic early intervention can prevent future PTSD, but some interventions like critical incident stress debriefing may actually increase risk.

Resilience is the most common response to trauma, although perhaps one-third of cases of PTSD become chronic.

Dissociative disorders are persistent, maladaptive disruptions in the integration of memory, consciousness, or identity.

Somatic symptom disorders involve complaints about physical symptoms that create psychological distress either out of pro- portion to actual physical problems or in the absence of a diag- nosable physical illness

Dissociative identity disorder (DID), also known as multiple personality disorder, is a dramatic problem character- ized by the existence of two or more distinct personalities in a single individual, but the diagnosis is rare and very controversial.

The term conversion disorder accurately conveys the central assumption of the diagnosis—the idea that psychologi- cal conflicts are converted into physical symptoms. The disorder involves diagnosis by exclusion, raising important concerns that some real but rare physical illness has been overlooked.

Summary7

7.1 How does DSM-5 define trauma? DSM-5 defines trauma as exposure to actual or threatened death, serious injury, or sexual violation. . . (see page 180).

7.2 Does trauma always lead to PTSD? Because not every traumatized person develops a disorder, trauma is a necessary but not a sufficient cause. What increases risk or resil- ience in the face of trauma? . . . (see page 182).

7.3 Can the unconscious mind cause mental disorders? Both Janet and Freud were eager to explain hysteria, and both developed theories of unconscious mental processes to do so. . . (see page 187).

7.4 What are recovered memories? Our concern about so-called recovered memories extends well be- yond the Franklin case . . . (see page 188).

7.5 Is multiple personality disorder real? Some experts even doubt the very existence of DID, arguing that DID is created by the power of suggestion. . . (see page 193).

7.6 Were conversion disorders common in Freud’s time? No one knows how prevalent conversion disorders were during the time of Charcot, Janet, and Freud, but the literature of the period suggests that they were common . . . (see page 199).

critical thinking review

The Big Picture

acute and posttraumatic stress disorders, dissociative disorders, and somatic symptom disorders CHAPTER 7 205

key terms acute stress disorder

(ASD) 175 body dysmorphic

disorder 199 conversion disorder 197 depersonalization/derealization

disorder 190

dissociation 175 dissociative amnesia 190 dissociative disorders 186 dissociative fugue 190 dissociative identity disorder

(DID) 191 factitious disorder 199

flashbacks 176 hypnosis 188 hysteria 187 iatrogenesis 195 malingering 199 multiple personality

disorder 191

posttraumatic stress disorder (PTSD) 175

somatic symptom disorder 198

traumatic stress 175

stress and physical health

8

stress and physical health CHAPTER 8 207

8 The Big Picture learning objectives

8.1 How can stress make you physically ill?

8.2 What are some good ways of coping with stress?

8.3 What does it mean to say people are resilient?

8.4 Does stress really play a role in diseases like cancer and AIDS?

8.5 What is a “lifestyle disease”?

8.6 What is “Type A” behavior? Can it really cause heart attacks?

How do you feel when you are “stressed out”? Different people feel jittery, tired, down, preoccupied, vigilant, defeated, angry, sick, or just plain lousy. How do you cope? Some people try to eliminate stress by solving the problem; others calm themselves by writing or talking about the stress; and still other people distract themselves in healthy ways like exercising or unhealthy ones like smoking or drink- ing. Can stress really make you sick? How? What physical illnesses are caused by stress? And, actually, what is stress anyway?

Overview Scientists define stress as any challenging event that requires phys- iological, cognitive, or behavioral adaptation. Stress may involve minor, daily hassles, like taking an exam, or major events, such as going through a divorce. The most common daily stressors in- volve interpersonal arguments and tensions (Almeida, 2005). As we saw in Chapter 7, traumatic stress involves exposure to actual or threatened death, serious injury, or sexual violence. This chap- ter is about normal stress, how we cope with it, and how stress affects our physical health.

Scientists once thought that stress contributed to only a few physical diseases. Ulcers, migraine headaches, hypertension (high blood pressure), asthma, and a few other illnesses were thought

to be psychosomatic disorders,1 a product of both the psyche (mind) and the soma (body) (Harrington, 2008). Today, the term is out- dated. Medical scientists now view every physical illness—from colds to cancer to AIDS—as a product of the interaction between the mind and body. Thus, there is no list of psychosomatic disor- ders in the DSM-5 or elsewhere.

This holistic view of health and disease has brought about major changes in medicine. Behavioral medicine is a mul- tidisciplinary field that includes both medical and mental health professionals who focus on psychological influences on the symptoms, cause, and treatment of physical illnesses. Psychologists who specialize in behavioral medicine often are called health psychologists.

Learning more adaptive ways of dealing with stress can limit the recurrence or improve the course of many physical illnesses (Lazarus, 2000; Snyder, 1999). In order to promote health, spe- cialists in behavioral medicine therefore encourage healthy cop- ing through stress management, proper diet, regular exercise, and avoidance of tobacco use. In treating diseases, behavioral medi- cine includes interventions such as educating parents of chroni- cally ill children, teaching strategies for coping with chronic pain, and running support groups for people with terminal cancer.

In this chapter, we discuss innovations in behavioral med- icine and review evidence on the link between stress and some major physical illnesses. In order to illustrate the challenges in studying stress, we also include an extended discussion of the number one killer in the United States today, cardiovascular dis- ease. We begin with a case study.

Bob Carter’s Heart Attack One Thursday afternoon, Bob Carter, a salesman for a beer and liquor wholesaler, was completing his route, calling on customers. Throughout the morning, he had felt a familiar discomfort in his chest and left arm. As had happened on occasion for at least a year, that morning he experienced a few fleeting but sharp pains in the center and left side of his chest. This was followed by a dull ache in his chest and left shoulder and a feeling of congestion in the same areas. Breathing deeply made the pain worse, but Bob could man- age it as long as he took shallow breaths. He continued on his route, alternately vowing to see a doctor soon and cursing his aging body.

After grabbing a hamburger for lunch, Bob called on a cus- tomer who was behind in his payments. At first, Bob shared a ciga- rette with the customer and chatted with him in a friendly way. He was a salesman, after all. Soon it was time to pressure him about the bill. As Bob raised his voice in anger, a crushing pain returned to his chest and radiated down his left arm. This was much worse than anything he had experienced before. The pain was so intense that Bob was unable to continue speaking. He slumped forward against the table, but with his right arm he waved away any attempt to help him. After sitting still for about 10 minutes, Bob dragged himself to his car and drove to his home 30 miles away. When his wife saw

1In everyday language, we sometimes use the term psychosomatic to imply that an illness is imagined or not real. But unlike conversion disorders (Chapter 7), psychosomatic disorders involve very real physical damage or dysfunction.

208 CHAPTER 8 stress and physical health

cardiologist chastised Bob, he promised to renew his efforts. How- ever, he thought to himself that giving up these small pleasures would not make him live any longer. It would just seem that way.

The case of Bob Carter illustrates how stress can contribute to coronary heart disease, but it also raises a number of questions. What is the physiological mechanism that transforms psychologi- cal stress into coronary risk? Is stress the problem, or is the real culprit the unhealthy behaviors that result from stress—smoking, drinking, and overeating? What is the role of personality in stress? Can someone like Bob change his lifestyle, and, if so, does this lower the risk for future heart attacks? We consider these and re- lated questions in this chapter. First, though, we need to consider more carefully exactly what we mean by “stress.”

Defining Stress We define stress as a challenging event that requires physiologi- cal, cognitive, or behavioral adaptation. However, we need to examine this definition closely. Is stress the event itself? Some

him shuffle into the house looking haggard and in obvious pain, she called for an ambulance. The Carters soon discovered that Bob had suffered a myocardial infarction (a heart attack).

Bob was 49 years old. His home life was happy, but it also put a lot of pressure on him. His 24-year-old daughter was living at home while her husband was serving in combat overseas. Nat- urally, the entire family was anxious about the son-in-law’s well- being. More stress came from Bob’s 21-year-old daughter, who had just graduated from college and was getting married in three weeks. Finally, Bob’s 19-year-old son was home from his first year of college, full of ideas that challenged Bob’s authority.

Bob also put plenty of stress on himself at work. A former high school athlete, he had always been competitive and hard- driving. He wanted to be the best at whatever he did, and right now his goal was to be the best salesman in his company. Bob used his charm, humor, and some not-so-gentle pressure to sell his products, and it worked. But once he had become the best salesman in his company, Bob wanted to be the best salesman for the producers whose products he sold. No matter what he ac- complished, Bob drove himself to meet a new goal.

Bob maintained his drive and competitiveness from his youth- ful days as a star athlete, but he had not maintained his physical condition. The only exercise he got was playing golf, and he usu- ally rode in a cart instead of walking the course. He was at least 30 pounds overweight, smoked a pack and a half of cigarettes a day, ate a lot of fatty red meat, and drank heavily. Bob was a good candidate for a heart attack.

Bob recuperated quickly in the hospital. He was tired and in considerable pain for a couple of days, but he was telling jokes before the end of a week. His cardiologist explained what had happened and gave Bob a stern lecture about changing his life- style. He wanted Bob to quit smoking, lose weight, cut down on his drinking, and gradually work himself back into shape. He urged Bob to slow down at work and told him to quit worrying about his children—they were old enough to take care of themselves.

To underscore these messages, the cardiologist asked a psy- chologist from the hospital’s behavioral medicine unit to consult with Bob. The psychologist reviewed information on coronary risk and gave Bob several pamphlets to read. The psychologist also explained that the hospital ran several programs that might in- terest Bob, including workshops on stress management, weight reduction, and exercise. Fees were minimal, because the hospi- tal offered them as a community service. The psychologist also offered to talk to Bob, because cardiac patients and their fami- lies sometimes have trouble adjusting to the sudden reminder of the patient’s mortality. But Bob waved off the offer of assistance much as he had waved off help in the middle of his heart attack.

Bob was discharged from the hospital five days after being admitted. Against his doctor’s advice, he walked his daughter down the aisle at her wedding the following weekend, and he was back to work within a month. At his six-week checkup, Bob admitted that he was smoking again. His weight was unchanged, and his exercise and drinking were only a “little better.” When the

Stress is a part of life, whether you are taking the SAT exam or even celebrating life-changing, positive events like getting married.

stress and physical health CHAPTER 8 209

Ratings on the SRRS and similar instruments are correlated with a variety of physical illnesses (Dohrenwend, 2006; Miller, 1989). Critics note, however, that stress checklists (1) rely on retrospective reports; (2) contain stressors that do not apply to people of different ages and ethnic backgrounds (Contrada et al., 2001) (Is the SRRS a good measure of college student stress?); (3) treat both positive and negative events as stressors (Would you equate getting married with getting fired?); (4) fail to distinguish between short-lived and chronic stressors; and most importantly, (5) treat the same event as causing the same amount of stress for everyone (Is getting pregnant just as stressful for an unwed teen- ager as it is for a married couple who want a baby?).

Dohrenwend and colleagues (1990) demonstrated the im- portance of this last point. They found, for example, that an as- sault caused a large change for nearly 20 percent of respondents, but it caused no change for the same percentage of people (see Table 8.2 on p. 210).

people would relax after becoming the top salesman, but Bob Carter viewed this achievement as another challenge. Perhaps stress should be defined in terms of the individual’s reactions to an event. But if we define stress in terms of the reactions it causes, is it merely circular logic to say stress has unwanted effects? In fact, scientists continue to debate whether stress is best defined as a life event itself or the event plus the individual’s reaction to it.

Stress as a Life Event Researchers often define stress as a life event—a difficult circum- stance regardless of the individual’s reaction to it. A measure that contributed greatly to the development of stress research, and still widely used, is Holmes and Rahe’s (1967) Social Readjustment Rating Scale (SRRS), a scale that assigns stress values to life events based on the judgments of a large group of normal adults. The SRRS views stressors that produce more life change units as caus- ing more stress (see Table 8.1).

TABLE 8.1 Change Caused by Different Life Events Life Event Life Change Units Life Event Life Change Units

Death of one’s spouse 100 Son or daughter leaving home 29

Divorce 73 Trouble with in-laws 29

Marital separation 65 Outstanding personal achievement 28

Jail term 63 Wife beginning or stopping work 26

Death of a close family member 63 Beginning or ending school 26

Personal injury or illness 53 Change in living conditions 25

Marriage 50 Revision of personal habits 24

Being fired at work 47 Trouble with one’s boss 23

Marital reconciliation 45 Change in work hours or conditions 20

Retirement 45 Change in residence 20

Change in the health of a family member 44 Change in schools 20

Pregnancy 40 Change in recreation 19

Sex difficulties 39 Change in church activities 19

Gain of a new family member 39 Change in social activities 18

Business readjustment 39 Mortgage or loan of less than $10,000 17

Change in one’s financial state 38 Change in sleeping habits 16

Death of a close friend 37 Change in number of family get-togethers 15

Change to a different line of work 36 Change in eating habits 15

Change in number of arguments with one’s spouse

35 Vacation 13

Mortgage over $10,000 31 Christmas 12

Foreclosure of a mortgage or loan 30 Minor violations of the law 11

Change in responsibilities at work 29

The SRRS rates different stressors as causing more or less life change for people. More difficult stressors have a higher number of “life change units.”

Source: Based on Holmes, TH and RH Rahe. The Social Readjustment Scale. Journal of Psychosomatic Research. 1967; 11(2): 213–218.

210 CHAPTER 8 stress and physical health

Stress as Appraisal of Life Events Because of this variability, many experts define stress as the com- bination of an event plus each individual’s reaction to it. Rich- ard Lazarus (1966) defined stress as the individual’s appraisal of a challenging life event. An impending exam is stressful when you feel inadequately prepared, but less so when you are confident. Lazarus also distinguished between people’s primary appraisal, our evaluation of the challenge, threat, or harm posed by an event, and people’s secondary appraisal, our assessment of our abilities and resources for coping with that event (Lazarus & Folkman, 1984). Thus, even if you feel unprepared, the impending exam causes less stress if you have the time and the ability to study.

The appraisal approach recognizes that the same event is more or less stressful for different people but runs the risk of

circular reasoning. What is stress? An event that causes us to feel threatened and overwhelmed. What causes us to feel threatened and overwhelmed? Stress. Logically, such a definition would be a tautology, a redundant statement that means nothing. Because of the potential tautology, researchers must carefully distinguish independent variables (stressors) from hypothesized dependent variables (adverse outcomes).

Symptoms of Stress Stress is an adaptive response to many aspects of living. If you had no stress response, you would not jump out of the way of a cement truck barreling down on you, let alone study for your exams!

The fight or flight response (in the cat, not the dog!).

TABLE 8.2 Different Reactions to the Same Life Event

Percentage of Subjects Reporting Each Amount of Change

Type of Event Large Moderate Little None

Serious physical illness 47.2% 27.8% 8.3% 16.7%

Relations with mate got worse 41.2 47.1 0.0 11.8

Relative died (not child/spouse) 8.3 8.3 29.2 54.2

Close friend died 5.3 15.8 29.8 49.1

Financial loss (not work related) 16.3 44.2 18.6 20.9

Assaulted 18.5 22.2 40.7 18.5

Broke up with a friend 0.0 26.1 37.0 37.0

Laid off 13.3 63.3 13.3 10.0

Had trouble with a boss 17.5 35.0 32.5 15.0

Got involved in a court case 9.5 9.5 28.6 52.4

Large percentages of people rate the same life event as causing large, moderate, little, or no change in their lives. This illustrates a key problem with assigning a set level of stress to any given life event, and more generally, of defining stress in terms of a stimulus alone.

Source: Based on Wong, Paul. Measuring Life Events: The Problem with Variability within Event Categories. Stress Medicine. July/September 1990. 6(3); 171–255.

stress and physical health CHAPTER 8 211

to many threats over the course of human evolution. But when your boss is yelling—or you worry that your boss might yell—the response only leaves your body racing and you feeling nervous and agitated.

ADRENAL HORMONES How does the stress response work physiologically? When a perceived threat registers in the cortex, it signals the amygdala, the brain structure primarily responsible for activating the stress response, which secretes corticotrophin-releasing factor (CRF). CRF stimulates the brainstem to activate the sym- pathetic nervous system. In response to the sympathetic arousal, the adrenal glands release two key hormones. One is epinephrine (commonly known as adrenaline), which acts as a neuromodulator and leads to the release of norepinephrine and more epinephrine into the bloodstream (see Figure 8.1 on p. 212). This familiar “rush of adrenaline” further activates the sympathetic nervous system.

The second key adrenal hormone is cortisol, often called the “stress hormone” because its release is so closely linked with stress. Cortisol has a less rapid action than adrenaline, yet it functions quickly to help the body make repairs in response to injury or infection. One function of cortisol is “containment” of pathogens in the body—the same function performed by the steroids that you may take for inflammation and skin irritation. Like externally administered steroids, however, cortisol can promote healing in

The renowned American physiologist Walter Cannon (1871–1945), one of the first and foremost stress researchers, recognized the adaptive, evolutionary aspects of stress. Can- non (1935) viewed stress as the activation of the fight-or-flight response,2 the reaction you witness when a cat is surprised by a barking dog. The cat can either scratch at the dog or flee to safety. The fight-or-flight response has obvious survival value. Cannon observed, however, that fight-or-flight is a maladaptive reaction to much stress in the modern world. Fight-or-flight is not an adaptive response to being reprimanded by your boss or giving a speech before a large audience. In other words, the human envi- ronment may have evolved more rapidly than our physiological reactions to it. (Some psychologists think that fight-or-flight is a male reaction to stress; see Tend and Befriend.)

Psychophysiological Responses to Stress Physiologically, the fight-or-flight response activates the sympa- thetic nervous system: Your heart and respiration rates increase, your blood pressure rises, your pupils dilate, your blood sugar levels elevate, and your blood flow is redirected in preparation for muscular activity (Baum et al., 1987; Koranyi, 1989). These physiological reactions heighten attention, provide energy for quick action, and prepare the body for injury (Sapolsky, 2003). This physiological reaction presumably was an adaptive response

2Ethologists now view mammals’ responses to threat as more nuanced: freeze-flight-fight-fright. Mammals’ first response to threat is to freeze (hide); if that fails, they flee; fighting is the third option. Fright or tonic immobility, also known as “playing dead,” is the final option when a threat is imminent and mortal (Bracha et al., 2004). Stress research is beginning to incorporate freeze-flight-fight-fright (Roelofs et al., 2010), but we use the fight-or-flight dichotomy, which dominates in current efforts.

Tend and Befriend: The Female Stress Response?

Health psychologist Shelly Taylor and her colleagues (2006) suggest that fight-or-flight may be a particularly male response to stress. Females, particularly primate females, may tend and befriend instead. Tending involves caring for offspring, especially protecting them from harm. Befriending involves social affiliation, finding safety in numbers, and sharing resources.

Theoretically, tend and befriend, like fight-or-flight, is a product of evolution. Inclusive fitness may be increased by caretaking and blending into the environment in response to threat. At- tachment is the mechanism hypothesized to underlie tending and befriending, but Taylor (2006) focuses on the benefits for the caretaker rather than the infant. She argues that evolution selected for caretaking tendencies in adult females.

Taylor and her colleagues (2000) suggested that, unlike male aggression, female aggression is activated less by sympathetic nervous system arousal (due to the lack of testosterone, the

male sex hormone). This limits the female’s fight response. Flight tendencies, in turn, are countered by oxytocin released by the pituitary and by the female sex hormone, estrogen. Theoreti- cally, the result is the activation of the parasympathetic nervous system, which has a calming effect.

Tend and befriend is a speculative hypothesis, but it focuses attention on important issues, for example, including more fe- males in studies of stress. Prior to 1995, males made up 83 per- cent of the participants in laboratory studies of stress. Moreover, evidence repeatedly shows major differences between women and men in response to stress, susceptibility to different dis- eases, and longevity, as women outlive men by five to 10 years in industrialized countries (Kajantie, 2008). Critics might see sexism in Taylor’s assertions about female–male sex differences, but Taylor carefully acknowledges cultural influences on gender roles. And under the right conditions, or through learning, males may also respond to stress by tending and befriending.

212 CHAPTER 8 stress and physical health

agents. Stress affects T cells, white blood cells that fight off antigens— foreign substances like bacteria that invade the body. This makes the body more susceptible to infectious diseases. The field of psycho- neuroimmunology (PNI) investigates the relation between stress and immune function (Adler, 2001; Song & Leonard, 2000).

Why would stress inhibit immune function? From an evolu- tionary perspective, heightened immune functioning might seem

the short run, but an excess of cortisol can harm the hippocam- pus, cause muscular atrophy, and produce hypertension (Song & Leonard, 2000; Yehuda, 2002). Watch the Video Hormonal Path- ways on MyPsychLab

IMMUNE SYSTEM RESPONSES The release of cortisol and CRF also cause immunosuppression, the decreased production of immune

CORTEX

AMYGDALA LOCUS CAERULEUS

BRAINSTEM

ADRENAL GLAND

1

2

3

8

4 9

5

7

6

GLUCOCORTICOID (CORTISOL)

EPINEPHRINE

NOREPINEPHRINE

CORTICOTROPIN-RELEASING HORMONE

FIGURE 8.1 Stress pathways are diverse and involve many regions of the brain in feedback loops that can sometimes greatly amplify a response. The process—simplified somewhat in this diagram—begins when an actual or perceived threat activates the sensory and higher reasoning centers in the cortex (1). The cortex then sends a message to the amygdala, the principal mediator of the stress response (2). Separately, a preconscious signal may precipitate activity in the amygdala (3). The amygdala releases corticotropin-releasing hormone, which stimulates the brain-stem (4) to activate the sympathetic nervous system via the spinal cord (5). In response, the adrenal glands produce the stress hormone epinephrine; a different pathway simultaneously triggers the adrenals to release glucocorticoids. The two types of hormones act on the muscle, heart, and lungs to prepare the body for “fight or flight” (6). If the stress becomes chronic, glucocorticoids induce the locus caeruleus (7) to release norepinephrine that communicates with the amygdala (8), leading to the production of more CRH (9)—and to ongoing reactivation of stress pathways. Source: © Pearson Education, Upper Saddle River, New Jersey.

stress and physical health CHAPTER 8 213

exhaustion. The first stage of alarm involves the mobilization of the body in reaction to threat. The next stage, resistance, is a period of time when the body is physiologically activated and prepared to respond to the threat. Exhaustion occurs if the body’s resources are depleted by chronic stress. Selye viewed the exhaustion as how stress causes physical illness. The body is damaged by continuous, failed attempts to reactivate the GAS (Selye, 1956).

Selye’s theory differs from Cannon’s in important ways. An analogy for Cannon’s theory is a car in which the engine contin- ues to race instead of idling down after running fast. An analogy for Selye’s is a car that has run out of gas and is damaged because stress keeps turning the key, trying repeatedly to restart the en- gine. A third mechanism also may be at work. The stress response may use so much energy that the body cannot do routine up- keep like storing energy or repairing injuries (Sapolsky, 1992). An analogy for this third theory is a car running at such high speeds that the cooling and lubricant systems cannot keep up, making a breakdown likely.

Coping People cope with stress in many ways, good and bad. Two ba- sic strategies are problem-focused and emotion-focused coping (Lazarus & Folkman, 1984). Problem-focused coping involves attempts to change a stressor. If your job is stressful, you look for a new one. Emotion-focused coping is an attempt to alter inter- nal distress. Before taking a big exam, you sit quietly and breathe deeply to calm yourself.

We all face a big problem in deciding how to cope: What will work? What if you are stressed out by poor grades in a dif- ficult class? Should you redouble your efforts, drop the course, or accept that this is not your best subject? Culturally, Americans prefer change over acceptance. Asian cultures, in contrast, em- phasize acceptance over change. What works best? We think that flexibility is the key. There is much truth in Reinhold Niebuhr’s “Serenity Prayer”:

God, give me the serenity to accept the things I cannot change;

The courage to change the things I cannot accept; And the wisdom to know the difference.

PREDICTABILITY AND CONTROL Events are less stressful when we are better prepared to cope with them. Studies of animals and humans show that predictability and control both dramatically reduce stress. For example, when a flash of light signals an im- pending shock, rats show a smaller stress response than when the shock is unsignaled (Sapolsky, 1992). The predictability allows animals (and humans, too) to begin to cope even before the onset of a stressor.

Animal research also shows the benefits of control. When they can stop a shock by pressing a bar, rats have a smaller stress response than when they have no control (Sapolsky, 1992). Even

to better prepare the body for the infection that may follow in- jury. However, the immune response creates inflammation, main- tains fever, and intensifies pain—all of which impair immediate action (Maier, Watkins, & Fleshner, 1994). Thus, immunosup- pression may actually be an adaptive short-term reaction to stress.

Current evidence suggests a response to stress that is more nuanced than blanket immunosuppression. Short-term stressors and physical threats enhance immune responses that are quick, require little energy, and contain infection due to an injury. How- ever, stress impairs immune responses that drain energy from the fight-or-flight response. Chronic stressors and losses (as opposed to threats) also create immunosuppression (Segerstrom, 2007; Segerstrom & Miller, 2004), perhaps permanently altering im- mune functioning in a way to explain associations between child- hood stress and diseases of aging (Miller, Chen, & Parker, 2011). Of interest, causality can work in the opposite direction: Immu- nosuppression can cause behavior change. Recently ill study par- ticipants are more vigilant in avoiding people who appear to be at risk for carrying infection (Miller & Maner, 2011).

ILLNESS AND CHRONIC STRESS Repeated stress can leave you susceptible to illness. Cannon (1935) hypothesized that this occurs because intense or chronic stress overwhelms the body’s homeostasis (a term he coined), the tendency to return to a steady state of normal functioning. He suggested that prolonged arousal of the sympathetic nervous system eventually damages the body, because it no longer returns to its normal resting state.

Canadian physiologist Hans Selye (1907–1982), another very influential stress researcher, offered a different hypothe- sis based on his concept of the general adaptation syndrome (GAS), which consists of three stages: alarm, resistance, and

A white blood cell called a macrophage (colored yellow) attacks bacteria (blue).

214 CHAPTER 8 stress and physical health

(Carver & Scheier, 1999; Kubzansky et al., 2001). Optimism about school predicts better immune functioning among law stu- dents (Segerstrom & Sephton, 2010). Stress is taxing, but less so if we approach it as a challenge instead of as an obstacle.

RELIGION Surprisingly, psychologists have only recently begun to study the health benefits of religious coping (Hill & Parga- ment, 2003). Evidence demonstrates that mortality risk is lower among those who attend church services, probably as a result of improved health behavior (Powell, Shahabi, & Thoresen, 2003; Schnall et al., 2008). Forgiveness, a religious and philosophical virtue, apparently also offers earthly benefits; it improves health (Witvliet, Ludwig, & Vander Laan, 2001).

Forgiveness can be healthful, as can finding meaning in life either through or outside of religion (Yanez et al., 2009). Other research shatters some misconceptions about religious coping, which often is thought to only promote acceptance of God’s will. A study of 200 Latinos with arthritis found that religion encour- aged active, not passive, coping—and led to less pain, less depres- sion, and improved psychological well-being (Abraído-Lanza, Vásquez, & Echeverría, 2004). Religious beliefs can help sufferers to gain control with God, not just to accept control by God (Par- gament & Park, 1995). This distinction is critical, since passive religious coping may worsen health while active religious coping enhances it (Edwards et al., 2009; see Critical Thinking Matters).

Health Behavior Stress can affect health directly, but stress also contributes to illness indirectly by disrupting health behavior (Cohen & Williamson, 1991; see Figure 8.3). Health behavior is any action that promotes

the illusion of control can help to alleviate stress. However, the perception of control increases stress when people believe they could have exercised control but failed to do so, or when they lose control over a formerly controllable stressor (Mineka & Kihlstrom, 1978). Control lessens stress when we have it, even when it is illusory, but failed attempts at control intensify stress.

OUTLETS FOR FRUSTRATION Physical activity also reduces physiological reactions to stress, even when the effort does not in- clude problem-focused coping. For example, rats secrete less cor- tisol following an electric shock if they can attack another rat or run on a running wheel (Sapolsky, 1992). Sounds like you at the gym—or dumping on your roommates? Having outlets for frus- tration does reduce stress.

REPRESSION Repression, keeping feelings bottled up, is a mal- adaptive form of emotion-focused coping (Cramer, 2000; Somer- field & McCrae, 2000). People who report positive mental health but whom clinicians judge to have emotional problems (so-called “defensive deniers”) show greater psychophysiological reactions to stress (Shedler, Mayman, & Manis, 1993). On the flip side, stress is reduced when people talk about their stressful experiences, es- pecially when stress is uncontrollable, you are comfortable talking about your emotions, and close others are supportive (Stanton & Low, 2012).

OPTIMISM Optimism is a healthy coping style. Pessimists are defeated from the outset. Optimists have a positive attitude about dealing with stress, even when they cannot control it. Posi- tive thinking is linked with better health habits and less illness

CRITICAL THINKING matters

Resilience

Popular culture, and much psychological research, tells us that stress is bad, something to be avoided. Stress will make us tense, irritable, and unhappy. Stress makes us sick. Stress can make us more susceptible to illness, but a little critical thinking leads us to ask: Are we really so vulnerable to stress? After all, humans evolved in stressful, often dangerous environ- ments. Evolution must have selected for successful strategies for coping with stress, not crumbling in the face of it. And stress is a part of everyday life, often a good part—a challenge. We typically expect to rise to the challenge of a sporting event, a difficult class, even a crisis in our lives. Does it make sense that humans are fragile in the face of stress?

The answer is “No” according to proponents of positive psychology, an approach that highlights human psychological strengths (Linley & Joseph, 2005). Positive psychologists instead

see pervasive human resilience, the ability to cope successfully with the challenges of life, including very stressful ones. Most people overcome not only normal stress but traumatic stress too. For example, most people do not develop PTSD following trauma; most people who lose a loved one are not overcome by depression in their grief (Bonanno, 2004).

Not only are most people resilient, but some people grow—they get stronger—as a result of stress (Linley & Joseph, 2005). For example, J.K. Rowling was divorced, depressed, and nearly broke before she wrote the Harry Potter series. In fact, research shows a U-shaped relationship between adversity and many measures of well-being. Too much stress can be harmful but so can too little (Seery, 2011; see Figure 8.2)

Resilience lies partly within the individual—for example, positive affect is related to many indices of health (Cohen &

stress and physical health CHAPTER 8 215

behavior like excessive smoking, drinking, and eating; (2) poverty due to large income disparities in the U.S.; (3) physical environ- ments that depend more on driving and less on exercise; and (4) health care systems that limit access to primary care.

MEDICAL ADVICE One very important health behavior is fol- lowing medical advice, something that as many as 93 percent of all patients fail to do fully (Taylor, 1990). This is a particu- lar problem for illnesses like hypertension (high blood pressure) that usually have no obvious symptoms. Patients may discontinue their medication, for example, because it offers no noticeable

good health. It includes healthy habits like a balanced diet, regu- lar sleep, and exercise, as well as avoiding unhealthy activities like cigarette smoking, excessive alcohol consumption, and drug use. Poor health habits, not stress per se, may be responsible for much of the relation between stress and illness (Bogg & Roberts, 2004).

Behavior is critical to health, and health behavior is in- fluenced by cultural as well as individual characteristics. The prestigious National Research Council (NRC) (2013) recently re- ported that life expectancy in the United States lags behind other high-income countries (see Table 8.3). The NRC (2013) blamed the discrepancy primarily on behavioral issues: (1) poor health

Pressman, 2006). Resilience also is partly attributable to social support and other aspects of environments (Roisman, 2005). One fascinating theory suggests that individual traits and envi- ronmental characteristics interact in important ways. According to this perspective, some people are “dandelions,” while oth- ers are “orchids.” Dandelions may not be beautiful, but they are the epitome of resilience. Dandelions grow everywhere, even when you try to kill them. Orchids can die, even when tended carefully. But in just the right environment, orchids explode with beauty (Ellis & Boyce, 2008). Although largely untested, the analogy offers a new, challenging perspective on resilience.

Whatever resilience is, it is a quality that most people possess in most circumstances. Stress can make us weaker, or it can make us stronger. While chronic, uncontrollable stress can break us down, most people find the strength they need to cope when confronted by stress.

The real-life Patch Adams inspired the film in which Robin Williams played the title role. Adams was a rebellious medical student in the 1960s who wanted to provide holistic care and instill optimism in his patients.

FIGURE 8.3 Direct and Indirect Effects of Stress on Physical Illness Stress may cause illness directly, for example, through suppression of immune functioning. Stress also may cause illness indirectly by causing poor health behavior.

Physical illnessStress

Health behavior

FIGURE 8.2 Life Adversity and Well-Being Too much stress—or too little stress—can be unhealthy. Moderate challenges help us to “exercise” coping skills. Source: Based on Seery, MD. Resilience: A silver lining to experiencing adverse life events? Current Directions in Psychological Science. 2011; 20: 390–394.

Global Distress

Functional Impairment

Life Satisfaction

PTS Symptoms

0.3

0.2

0.1

0

0 High

Cumulative Lifetime Adversity

z- Sc

o re

s

20.1

20.2

20.3

216 CHAPTER 8 stress and physical health

support in humans predicts improved immune, cardiovascular, and endocrine functioning (Schneiderman, Ironson, & Siegel, 2004).

People seek social support in different ways. Cultural differ- ences can be important. For example, Asians and Asian Americans benefit from implicit social support such as focusing on valued social groups. Explicit social support such as seeking advice and emotional solace does not buffer stress for Asians, but it does for European Americans (Taylor et al., 2007). And it sometimes is bet- ter to give than to receive. Providing social support promotes good health at least as much as receiving it does (Brown et al., 2003).

Of all potential sources of social support, a good marriage can be critical (Kiecolt-Glaser & Newton, 2001). One fascinating study admitted 90 newlyweds to a hospital research ward where the couples discussed marital problems for 30 minutes. Partners who were hostile or negative had more immunosuppression over the next 24 hours, and their blood pressure remained elevated, too (Kiecolt-Glaser et al., 1993). And a follow-up study found that epinephrine levels were 34 percent higher for couples who got divorced in the next 10 years (Kiecolt-Glaser et al., 2003). A conflicted marriage is bad for your health, and too much stress is bad for your marriage!

relief, even though it may control a dangerous underlying con- dition. Stress also can interfere with treatments that do affect symptoms. For example, family conflict makes children with insulin-dependent diabetes less likely to adhere to medical advice about exercise, diet, and testing blood sugars (Miller-Johnson et al., 1994).

ILLNESS BEHAVIOR Illness behavior—behaving as if you are sick—also is stress related. Increased stress is correlated with such illness behaviors as making more frequent office visits to physi- cians or allowing chronic pain to interfere with everyday activities (Taylor, 1990). Effective coping is partly a matter of perception, including ignoring of some physical discomfort and living life as normally as possible, particularly when coping with chronic illness (Petrie & Weinman, 2012).

SOCIAL SUPPORT Social support both encourages positive health behavior and has direct, physical benefits (Uchino, 2009). Even stressed monkeys exhibit less immunosuppression when they interact more with other monkeys (Cohen et al., 1992). Stressed rabbits develop clogged arteries more slowly if they af- filiate with other rabbits (McCabe et al., 2002). Increased social

TABLE 8.3 Life Expectancy in Seventeen High-Income Countries

Males Females

Rank Country LE Rank Country LE

1 Switzerland 79.33 1 Japan 85.98

2 Australia 79.27 2 France 84.43

3 Japan 79.20 3 Switzerland 84.09

4 Sweden 78.92 3 Italy 84.09

5 Italy 78.82 5 Spain 84.03

6 Canada 78.35 6 Australia 83.78

7 Norway 78.25 7 Canada 82.95

8 Netherlands 78.01 7 Sweden 82.95

9 Spain 77.62 9 Austria 82.86

10 United Kingdom 77.43 10 Finland 82.86

11 France 77.41 11 Norway 82.68

12 Austria 77.33 12 Germany 82.44

13 Germany 77.11 13 Netherlands 82.31

14 Denmark 76.13 14 Portugal 82.19

15 Portugal 75.87 15 United Kingdom 81.68

16 Finland 75.86 16 United States 80.78

17 United States 75.64 17 Denmark 80.53

The United States has the lowest life expectancy among major high-income countries largely due to behavioral issues includ- ing poor health behavior, poverty, physical environments that discourage exercise and limited access to primary care.

Source: Courtesy of Thomas F. Oltmanns and Robert E. Emery.

stress and physical health CHAPTER 8 217

Diagnosis of Stress and Physical Illness The DSM-5 classifies stress related to physical illness as Psycho- logical Factors Affecting Other Medical Conditions. This diagnosis is a part of a new DSM-5 category called Somatic Symptom and Other Disorders, which also includes problems like conversion disorder, where psychological issues are prominent but the physi- cal symptoms often are medically unexplained (and may involve symptoms that make no medical sense) (see Chapter 7). DSM-5 grouped stress-related physical illnesses together with other so- matic symptom disorders for the obvious reason that they all include physical symptoms and often are treated as medical set- tings. The new category, somatic symptom disorders, may have practical benefits for medical practitioners, but we question its conceptual basis (see Thinking Critically About DSM-5).

Illness as a Cause of Stress Stress can cause illness, but illness also causes stress. For example, consider the effects of the diagnosis of insulin-dependent diabetes on a 10-year-old boy and his family. In order to maintain a normal range of blood sugar, the child and his parents must frequently test his blood, adjust to giving and receiving one, two, or three injections of insulin daily, and carefully monitor exercise and diet because of their effects on blood sugar. In addition, the child and his family must somehow cope with the stigma of being “different.” Finally, they have to learn to cope with the possibility of him suffering long- term side effects from hyperglycemia (high blood sugar), including kidney dysfunction or blindness. As this example suggests, helping children, adults, and families cope with the stress of chronic illness is an important part of behavioral medicine (Martire & Schulz, 2007).

THINKING CRITICALLY about DSM-5

Is the Descriptive Approach Too Literal Sometimes?

DSM-5 takes a descriptive approach to classification, bas-ing a diagnosis on similar, observed symptoms. The descriptive approach has advantages, as we discussed in Chapter 4. Perhaps the foremost advantage is reliability. Different clinicians are more likely to agree about a diagnosis that is based on observable symptoms.

The DSM-5 also follows a descriptive approach when grouping diagnoses into broader categories. For example, the new diag- nostic category, somatic symptom disorders, combines psycho- logical factors affecting other medical conditions together with conversion disorder and other problems that involve somatic symptoms (reviewed in Chapter 7). It is hard to argue with the practical reason DSM-5 made this change: Somatic symptom disorders all involve physical symptoms and are usually treated in medical settings by medical practitioners.

Yet, we do not want you to follow DSM-5 slavishly or uncritically. Diagnostic classifications can be based on many grounds. We decided, for example, to discuss dissociative disorders and con- version disorder together in Chapter 7 because of their historical (“hysteria”) and conceptual (unconscious processes) association. (We did place psychological factors affecting other medical con- ditions adjacent to other DSM-5 somatic symptom disorders to help you understand and appreciate DSM-5’s approach.)

When we teach abnormal psychology, we do a class demon- stration to make the point that classifications can be based on many, different criteria. We bring a couple of dozen items from our desk, and ask students to sort them into categories. All of the items can be grouped together as desk materials. But we can also group them based on their function: pens, pencils, a computer keyboard; staples, paper clips, scotch tape; scissors, a wood letter opener. Or we can group them based on the main material in the object: pencils, letter opener (wood); staples,

paper clips, scissors (metal); computer keyboard, pens, scotch tape (plastic). Or we can group them according to psychoana- lytic theory: pens, pencils, scissors, letter opener; everything else. (What’s the theory? Phallic symbols!)

We question DSM-5’s descriptive approach to a number of prob- lems (and we want you to question DSM-5 too). To offer another example, pica, eating nonfood substances (e.g., paper) is now classified as an eating disorder. Sure, pica involves eating issues, as do anorexia nervosa and bulimia nervosa (see Chapter 10). But anorexia and bulimia have a lot in common. They both in- clude major issues with body image, often have an onset in adolescence, are much more common among women, are influenced by cultural standards of beauty, and so on. Pica typi- cally occurs among very young children, particularly children with intellectual disabilities or autism spectrum disorders (see Chapter 15). Is DSM-5 being too literal in grouping these prob- lems together based on their appearance? We think so. It is a bit like you saying that staples, paper clips, and scissors have to go together. They are all shiny and sliver!

Critical thinking requires much more than memorization. Of course, we want you to learn about the DSM-5 diagnoses, but we also want you to understand and evaluate the diagnostic system. Our goal is not to criticize DSM-5. Our goal is to help you think more deeply about the DSM-5 and all kinds of scientific classifica- tions. Is Pluto a planet? Why is plasma different from gas?

Who knows? Maybe you will help to create a new, improved ver- sion of the DSM one day. For now, just remember this: Classify- ing symptoms and disorders together based on their description is a reasonable approach at this point in the evolution of the di- agnosis of mental disorders. Yet, the descriptive approach is not necessarily the best way to classify psychological problems. And it certainly is not the only way.

218 CHAPTER 8 stress and physical health

in public health, far fewer people die of infectious diseases now. Today, most of the leading causes of death are lifestyle diseases that are affected by stress and health behavior (Human Capital Initia- tive, 1996; see Figure 8.4).

In the following sections we briefly review evidence on stress and lifestyle in the cause, course, and treatment of cancer, HIV infection, chronic pain, and sleep disorders. After this, we con- sider in some detail the relation between stress and today’s num- ber one killer, cardiovascular disease.

Cancer Cancer is the second leading cause of mortality in the United States today, accounting for 23 percent of all deaths. At first glance, cancer may seem to be a purely biological illness, but the

Psychological Factors Affecting Other Medical Conditions may involve any physical illness. There is no subset of “psycho- somatic” disorders. The psychological factors may include dis- tress, interaction patterns, coping styles, or maladaptive health behaviors, not necessarily a mental disorder (see “DSM-5: Psychological Factors Affecting Other Medical Conditions”).

Psychological Factors and Some Familiar Illnesses At the beginning of the twentieth century, infectious diseases, specifically influenza, pneumonia, and tuberculosis, were the most common causes of death in the United States (Taylor, 1995). Thanks to advances in medical science, and especially

FIGURE 8.4 Stress and health behavior play a central role in most of the major causes of death in the United States today.

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Psychological Factors Affecting Other Medical Conditions

A. A general medical symptom or condition (other than a mental disorder) is present.

B. Psychological or behavioral factors adversely affect the medical condition in one of the following ways: 1. The factors have influenced the course of the medical con-

dition as shown by a close temporal association between the psychological factors and the development or exacer- bation of, or delayed recovery from, the medical condition.

2. The factors interfere with the treatment of the general medical condition (e.g., poor adherence).

3. The factors constitute additional well-established health risks for the individual.

4. The factors influence the underlying pathophysiology, precipitating or exacerbating symptoms or necessitat- ing medical attention.

DSM-5

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

stress and physical health CHAPTER 8 219

comparison to patients who received no psychosocial treatment (29 percent) (Fawzy et al., 1993). Sadly, hopes have been dashed by repeated failures to replicate this optimistic result (Coyne et al., 2009). Still, the benefits of support groups for quality of life, if not longevity, are important, and include less social disrup- tion, greater well-being, and more positive affect (Antoni et al., 2006; Brothers et al., 2011).

Acquired Immune Deficiency Syndrome (AIDS) Acquired immune deficiency syndrome (AIDS) is caused by the human immunodeficiency virus (HIV), which attacks the immune system and leaves the patient susceptible to infection, neurological complications, and cancers that rarely affect people with normal immune function. HIV-positive patients vary widely in how rapidly they develop AIDS. Some develop AIDS within months; others remain symptom-free for 10 years or more.

In 1981, AIDS was diagnosed for the first time; in 1996, it was the eighth leading cause of death in the United States (Peters, Kochanek, & Murphy, 1998). HIV and AIDS also reached epi- demic proportions in other parts of the world, with a notably high prevalence in Africa. In the United States, over 1 million cases of HIV/AIDS have been reported to the Centers for Disease Control and Prevention (CDC) (CDC, 2008). Fortunately, death due to AIDS has declined rapidly since the middle of the 1990s due to treatments that do not cure the illness but do promote a longer, healthier life. As a result, AIDS no longer is among the 15 leading causes of death in the United States (Minino & Smith, 2001).

Behavioral factors play a critical role in the transmission of HIV. Scientists have yet to determine precisely how HIV is trans- mitted, but researchers have isolated a number of high-risk behav- iors. Contact with bodily fluids, particularly blood and semen, is very risky. The CDC reports that the highest incidence of new cases of HIV are among men who have unprotected sex with men and individuals who participate in high-risk heterosexual sexual intercourse, such as unprotected anal and vaginal intercourse

importance of psychological factors quickly becomes apparent. For example, health behavior such as cigarette smoking contrib- utes to exposure to various carcinogens, cancer-causing agents.

Psychological factors also are at least modestly associated with the course of cancer (McKenna et al., 1999). Not surpris- ingly, cancer patients often are anxious or depressed, and com- monly suffer “cancer-related fatigue,” a condition attributable to both emotional factors and the physical side effects of cancer treatments like chemotherapy (Kangas et al., 2008). Negative emotions can lead to increases in poor health behavior such as alcohol consumption and decreases in positive health behavior such as exercise. PTSD among cancer patients also is quite com- mon (Kangas, Henry, & Bryant, 2005).

The absence of social support also can undermine compliance with unpleasant but vitally important medical treatments (Ander- son, Kiecolt-Glaser, & Glaser, 1994). Cancer patients who are more emotionally expressive miss fewer medical appointments, report a better quality of life, and maintain a better health status (Stanton et al., 2000). And in facing the specter of cancer, the encouragement and physical assistance of family and friends can boost patients’ resolve to bear side effects such as hair loss and intense nausea. Of course, a diagnosis of cancer is a source of considerable emo- tional distress to loved ones, as well as to victims (Hagedoorn et al., 2008). For example, partners’ reactions to breast cancer predict relationship quality a year later (Wimberly et al., 2005).

Stress also may directly affect the course of cancer. In animal studies, rats exposed to inescapable shock are less able to reject implanted cancer tumors than rats exposed to escapable shock or no stress at all (Visintainer, Seligman, & Volpicelli, 1982). Immu- nity plays an important role in limiting the spread of cancerous tumors, and immunosuppression due to stress may disrupt this protective function (Anderson, Kiecolt-Glaser, & Glaser, 1994).

Can psychological treatment alter the course of cancer? One early study found that, six years after treatment, significantly fewer patients who participated in a support group died (9 percent) in

Social support helps cancer patients cope with uncomfortable treatments and side effects, while improving their quality of life.

Basketball superstar Ervin (Magic) Johnson became a spokesman for increasing awareness of HIV and AIDS after he tested HIV positive.

220 CHAPTER 8 stress and physical health

are associated with depression and anxiety (Gatchel et al., 2007), and, conversely, higher levels of positive affect predict lower levels of reported pain (Zautra, Johnson, & Davis, 2005). People who are anxious or depressed may be more sensitive to pain, less able to cope with it, and simply more willing to complain (Pincus & Morley, 2001).

Many experts view insight-focused psychotherapy as counter- productive and potentially damaging in treating pain (Keefe et al., 2001). More direct treatments include relaxation training and cog- nitive therapy. Each approach has some research support, but pain reduction typically is modest (Patterson, 2004). Most efforts there- fore focus on the pain management, not pain reduction. The goal of pain management is to help people to cope with pain in a way that minimizes its impact on their lives, even if the pain cannot be eliminated or controlled entirely. Programs typically include educa- tion about pain and its consequences, pain control methods such as relaxation or exercise, attempts to change maladaptive expectations about pain, and interventions with families or support groups.

Pain management programs can help with a wide variety of problems, including headaches, lower back pain, and facial pain. Following treatment, patients report greater satisfaction with their life and relationships, improved employment status, and less reliance on medication. Once they are better able to func- tion in their lives, patients also often say that their pain has less- ened (Gatchel et al., 2007). Improved life functioning may alter patients’ awareness of discomfort, but emerging research suggests that treatment may directly alter the experience of pain. Tech- niques like distraction, relaxation, and reappraisal (e.g., labeling a shot as pressure instead of pain) not only lead to reduced reports of pain but also to less activation of pain processing circuitry in the brain (Edwards et al., 2009).

Sleep-Wake Disorders Historically, sleep disturbances were of concern to mental health professionals only secondarily, as a symptom of a mental disorder such as depression or anxiety. However, DSM-5 includes a variety

(CDC, 2008). The use of condoms greatly reduces the risk of the sexual transmission of HIV. Other factors that increase the risk for HIV infection include intravenous drug use and mothers in- fected with HIV who transmit the infection to their unborn chil- dren (U.S. Department of Health and Human Services, 1993). A tricky problem for HIV-positive mothers is telling growing chil- dren about their HIV status. Fortunately, recent evidence shows that focused psychological intervention encourages disclosure— with benefits for both mothers and school-aged children (Mur- phy et al., 2011).

Scientists and policymakers have launched large-scale media campaigns to educate the public about HIV and AIDS and to change risky behavior. Are they effective? Evidence indicates that prevention efforts produce significant but small changes in behav- ior (for example, condom use). Knowledge and attitudes change more, and more rapidly, than behavior (Albarracín, Durantini, & Earl, 2006). The most effective programs focus on changing spe- cific behaviors and attitudes; the least effective programs use fear tactics (Albarracín et al., 2005). Unfortunately, but perhaps not surprisingly, the people most interested in participating in HIV change programs are the ones already engaged in less risky behav- ior (Earl et al., 2009).

Stress is linked with a more rapid progression of HIV, while social support is associated with a more gradual onset of symp- toms (Evans et al., 1997; Leserman et al., 1999). Support groups lower distress among treated patients, but no benefits for longev- ity have been found. Broader social support also is extremely im- portant to the AIDS patient’s social and psychological well-being. Unfortunately, misunderstanding and fear cause many people, including many health professionals, to distance themselves from AIDS rather than offering understanding and support.

Pain Disorder Pain is adaptive. Pain signals that something is wrong, and it mo- tivates people to seek treatment for acute injuries and illnesses. But pain is not always useful. In many cases, pain is not a sign of an underlying condition that can be treated. Examples of mal- adaptive pain include recurrent acute problems like headaches or chronic ones like lower back problems. In such circumstances, the DSM-5 diagnosis of Somatic Symptom Disorder (with pre- dominant pain) may apply.

Pain can take a huge toll on the sufferer, family members, and financial resources. In a typical day, 28.8 percent of Ameri- can men and 26.6 percent of women report feeling some pain (Krueger & Stone, 2008; see Figure 8.5). The past year preva- lence of chronic neck or back pain is 19 percent of the U.S. pop- ulation (Von Korff et al., 2005). Perhaps 50 million Americans experience some type of dysfunctional pain, costing society $70 billion in annual health care (Gatchel et al., 2007).

Pain is subjective. This makes pain difficult to evaluate, par- ticularly when there is no identifiable injury or illness, as is com- mon with headaches and lower back pain. Reports of greater pain

FIGURE 8.5 Reports of routine pain intensity increase with age but are not strongly associated with gender in this nationally representative U.S. sample. 0 = no pain and 2 = slight pain.

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stress and physical health CHAPTER 8 221

vicinity. Circadian rhythm sleep disorder is a mismatch between the patients’ 24-hour sleeping patterns and their 24-hour life demands. The disorder is found more commonly among adoles- cents and people who work night shifts (APA, 2013).

“Parasomnias” are characterized by abnormal events that oc- cur during sleep, and include five types of sleep-wake disorders. Non-rapid eye movement sleep arousal disorders are characterized by incomplete awakening and either sleepwalking or sleep ter- rors, recurrent episodes of screaming or other signs of great fear. The patient has no memory of these episodes, which usually oc- cur during the first third of sleep, and may quickly fall back into sleep. Nightmare disorder, another parasomnia, is characterized by frequent awakening by terrifying dreams. Unlike sleep terrors, pa- tients remember nightmares and quickly orient to being awake. Rapid eye movement sleep behavior disorder, a third parasomnia, involves arousal during sleep associated with vocalization or com- plex motor behaviors, but unlike sleepwalking, the individual quickly awakens. A fourth parasomnia, restless legs syndrome, in- volves an urge to move the legs that disturbs sleep at least three times a week for three months and causes significant distress or impairment in functioning. The last parasomnia is substance/med- ication-induced sleep disorder which involves severe sleep distur- bances apparently caused by intoxication or medication.

Cardiovascular Disease We focus on cardiovascular disease as a more detailed example of stress research and treatment. Cardiovascular disease (CVD) is a group of disorders that affect the heart and circulatory system. The most important of these illnesses are hypertension (high blood pressure) and coronary heart disease (CHD). The most deadly

of Sleep-Wake Disorders where sleep is the primary complaint. The manual includes 10 categories of sleep-wake disorders.

Insomnia disorder is characterized by problems with sleep quan- tity or quality and may include problems in initiating or maintain- ing sleep. Insomnia disorder must occur three nights a week for three months and cause significant distress or impairment in functioning. Insomnia is a common problem, although people with insomnia of- ten overestimate how long it takes to fall asleep and underestimate their total sleep due to misperception, worry, and brief awakenings (Harvey & Tang, 2012). Effective treatments include stimulus control techniques (only staying in bed during sleep) and resetting circadian rhythms (going to bed and getting up at set times), as well as not nap- ping, regardless of the length of sleep (Morin et al., 2006). Internet- based programs can help alleviate insomnia (Ritterband et al., 2010).

Hypersomnolence disorder is excessive sleepiness despite at least getting at least seven hours’ sleep. Sleepiness leads to pro- longed sleep (more than nine hours), lapses into sleep during the day, or difficulty becoming fully awake. A similar problem is nar- colepsy, irresistible periods of need to sleep that are accompanied by specific physical symptoms such as brief, sudden loss of muscle tone precipitated by laughter (APA, 2013).

Breathing-related sleep disorders involve the disruption in sleep due to breathing problems. An example is “obstructive sleep ap- nea hypopnea,” the temporary obstruction of the respiratory air- way that causes loud snoring or breathing pauses, making sleep unrefreshing and causing sleepiness. Not surprisingly, sleep apnea disrupts both the patient’s sleep and the sleep of others in their

Estimates indicate that fifty million people in the United States experience some form of dysfunctional pain.

Cardiovascular disorders, including myocardial infarction (heart attack), are the leading cause of death in the United States and most industrialized countries.

222 CHAPTER 8 stress and physical health

no previous treatment for CHD, an indication that either there were no warning symptoms or the symptoms were mild enough to ignore. Research using portable electrocardiogram monitoring and diary recordings indicates that patients are unaware of many episodes (Krantz et al., 1993; Schneiderman, Chesney, & Krantz, 1989).

Diagnosis of CVD Myocardial infarction and angina pectoris are the two major forms of coronary heart disease. Angina pectoris involves intermittent chest pains that are usually brought on by some form of exertion. Attacks of angina do not damage the heart, but the chest pain can be a sign of underlying pathology. MI (heart attack) does involve damage to the heart, and it often causes sudden cardiac death, which is usually defined as death within 24 hours of a coronary episode.

Secondary hypertension results from a known problem such as a diagnosed kidney or endocrine disorder. It is called second- ary because the high blood pressure is a consequence of another physical disorder. Primary or essential hypertension is diagnosed when the high blood pressure is the principal or only disorder. There is no single, identifiable cause of essential hypertension, which accounts for approximately 85 percent of all cases of high blood pressure. Instead, multiple physical and behavioral risk fac- tors contribute to the elevated blood pressure.

Frequency of CVD Cardiovascular disease has been the leading killer in the United States since the 1920s, but the death rate due to CVD has de- clined by 25 percent or more in the United States, Japan, and many Western European countries. At the same time, mortality rates attributed to CVD have increased in many eastern Euro- pean countries. Some but not all of these trends are attributable to changes in diet, cigarette smoking, and blood pressure (Jen- kins, 1988). Another part of the explanation may be increased awareness of the negative effects of stress in the West—and the increased industrialization and increased stress in Eastern Europe.

Causes of CVD BIOLOGICAL FACTORS The immediate cause of CHD is the deprivation of oxygen to the heart muscle. No permanent dam- age is caused by the temporary oxygen deprivation (myocardial ischemia) that accompanies angina pectoris, but part of the heart muscle dies in cases of heart attack (myocardial infarction). Oxy- gen deprivation can be caused by temporarily increased oxygen demands on the heart, for example, as a result of exercise. More problematic is when atherosclerosis causes the gradual depriva- tion of the flow of blood (and the oxygen it carries) to the heart. Atherosclerosis is the thickening of the coronary artery wall that occurs as a result of the accumulation of blood lipids (fats) with age, and which also may be caused by inflammation resulting from stress (Black & Garbutt, 2002). The most dangerous cir- cumstance is when oxygen deprivation is sudden, as occurs in a

and well-known form of CHD is myocardial infarction (MI), commonly called a heart attack. Hypertension increases the risk for CHD, as well as for other serious disorders, such as strokes.

Cardiovascular disorders are the leading cause of mortality not only in the United States, where they account for over one- third of all deaths (Minino & Smith, 2001), but also in most industrialized countries. Mortality due to CHD is of particu- lar concern because victims of the disease tend to be relatively young. About half of all Americans with CHD and about a quar- ter of all stroke victims are under the age of 65 (Jenkins, 1988). Risk for CVD is associated with health behavior, including weight, diet, exercise, and cigarette smoking. Personality styles, behavior patterns, and emotional expression also can contribute to CVD (Rozanski, Blumenthal, & Kaplan, 1999).

Symptoms of CVD Hypertension is often referred to as the “silent killer” because it produces no obvious symptoms. For this reason, high blood pres- sure often goes undetected, and routine blood pressure monitor- ing is extremely important. Systolic blood pressure is the highest pressure that the blood exerts against the arteries. This occurs when the heart is pumping blood. Diastolic blood pressure is the lowest amount of pressure that the blood creates against the ar- teries. This occurs between heartbeats. Generally, hypertension is defined by a systolic reading above 140 and/or a diastolic reading above 90 when measured while the patient is in a relaxed state.

The most notable symptom of CHD is chest pain. Typically, the pain is centralized in the middle of the chest, and it often ex- tends through the left shoulder and down the left arm. In less severe forms of the disorder, the pain is mild, or it may be sharp but brief. The pain of myocardial infarction typically is so intense, however, that it is crippling. Two-thirds of all deaths from CHD occur within 24 hours of a coronary event (Kamarck & Jennings, 1991). In over half of these sudden deaths, the victim received

Over half of all victims of sudden death following myocardial infarction (heart attack) have no previous history of treatment for CHD.

stress and physical health CHAPTER 8 223

coronary occlusion. Coronary occlusions result either from arteries that are completely blocked by fatty deposits or from blood clots that make their way to the heart muscle.

The immediate biological causes of hypertension are less well understood, as are the more distant biological causes of both hy- pertension and CHD. A positive family history is a risk factor for both hypertension and CHD, and most experts interpret this as a genetic contribution. However, research using animal models of CVD suggests a gene-environment interaction. For example, rats prone to develop hypertension do so only when exposed to salty diets or environmental stress (Schneiderman et al., 1989).

PSYCHOLOGICAL FACTORS IN CVD Psychological influences on CVD include (1) health behavior, (2) immediate and more chronic stress, (3) personality, especially Type A behavior, and (4) depression and anxiety.

Health Behavior Several health behaviors are linked to CVD and especially CHD, which is why it is called a “lifestyle disease.” Hyper- tension increases the risk for CHD by a factor of two to four. The risk for CHD also is two to three times greater among those who smoke a pack or more of cigarettes a day. Obesity, a fatty diet, ele- vated serum cholesterol levels, heavy alcohol consumption, and lack of exercise also increase the risk for CHD. Weight, diet, cholesterol,

Employed women with children are more likely to suffer from heart disease than employed women without children or homemakers. Job strain includes conflict between work and family life.

RESEARCH methods

Longitudinal Studies: Lives over Time

Alongitudinal study involves studying people repeat-edly over time. The approach contrasts with the cross-sectional study in which people are studied at only one time point. A common goal of a longitudinal study is to determine whether hypothesized causes come before their as- sumed effects. We know that causes must precede effects in time. The bat is swung before the ball flies over the fence. If we demonstrate that stress precedes heart disease in longitudinal research, this helps scientists rule out the alternative interpreta- tion (reverse causality) that the illness caused the stress.

Longitudinal studies cost more. It is much less expensive to study stress and heart disease at one point in time than to assess stress now and CHD as it develops over the next 10 years. One way around the expense is to use a retrospective study (sometimes called “a follow-back study”). In this design, scientists look back- ward in time either by asking people to recall past events or by examining records from the past. The retrospective method is less expensive, but it is of limited value because of distorted memo- ries and limited records (see the Research Methods in Chapter 7).

The prospective design (sometimes called a follow-forward study) is a more effective but more expensive alternative.

In prospective research, supposed causes are assessed in the present, and subjects are followed longitudinally to see if the hypothesized effects develop over time. Using the fol- low-up method, scientists can assess a range of predictions more thoroughly and more objectively than in follow-back studies.

Researchers use both methods in studying health and illness (and abnormal psychology generally). When a finding is sup- ported in prospective longitudinal research, you can have greater confidence in an investigator’s causal hypothesis than in cross-sectional research. However, correlation does not mean causation, even in a longitudinal study. The supposed “cause” and the “effect” could both result from some third variable. For example, a researcher might find that Type A behavior measured at one point in time predicts CHD several years later. But chronic job stress may cause both Type A be- havior and later heart disease. Scientists need many studies using many different research methods to establish causation. And you need to understand the strengths and weaknesses of research methods in order to be an informed consumer of scientific information.

224 CHAPTER 8 stress and physical health

FIGURE 8.6 Occupations classified according to the degree of de- mand and control that are associated with them. Jobs with low control and high demands cause more job strain and increased cardiovascular risk. Source: Kranz, DS. Environmental stress and biobehavioral anteced- ents of coronary heart disease. . .” Journal of Consulting and Clinical Psychology. June 1988; 56(3): 333–341.

High psychological demandLow psychological demand

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alcohol consumption, and exercise all are highly correlated, but each appears to contribute independently to the disease (Jenkins, 1988).

Stress Stress contributes to CVD in at least two ways. First, over the long run, the heart may be damaged by constant stress. Second, stress immediately taxes the cardiovascular system, increasing the heart rate and blood pressure, which can precipitate sudden symp- toms or even an MI. A dramatic example of the immediate effects of stress was observed during the Los Angeles earthquake of 1994. Cardiac deaths on the day of the earthquake rose to 24 from an average of 4.6 the preceding week (Leor, Poole, & Kloner, 1996).

Increased blood pressure and heart rate are normal reactions to stress, but researchers have long observed that different people exhibit different cardiovascular reactivity to stress, greater or lesser increases in blood pressure and heart rate when exposed to stress in the laboratory. Are people who show greater cardiovascular re- activity to stress more likely to develop CVD?

Yes. In a study of patients with coronary artery disease, pa- tients who reacted to mental stress in the laboratory with greater myocardial ischemia (oxygen deprivation to the heart) had a higher rate of fatal and nonfatal cardiac events over the next five years in comparison to their less reactive counterparts. In fact, mental stress was a better predictor of subsequent cardiac events than was physical stress (exercise testing) (Jiang et al., 1996).

Chronic stress increases the risk for CVD and CHD (Krantz et al., 1988; Schneiderman et al., 2004). For example, increased

rates of CHD are found among people with high-stress occupa- tions. What appears to be most damaging is job strain, a situation that pairs high psychological demands with a low degree of deci- sional control (Karasek et al., 1982). A waitress has relatively high demands and low control, for instance, whereas a forest ranger has relatively few demands and a high degree of control. Figure 8.6 portrays a number of occupations and how they vary in terms of psychological demands and decisional control.

Several studies have found a relationship between job strain and CHD (Krantz et al., 1988; Rozanski et al., 1999). For example, the risk for CHD was one and one-half times higher among women who had high job strain based on objective evaluations of their occupations in the Framingham Heart Study, a major longitudinal study of the development of coronary heart disease (see Research Methods). The risk was three times higher among women whose self-reports indicated high job strain (LaCroix & Haynes, 1987).

Work strain is not limited to employment but also includes work that is performed in other life roles. In an earlier analy- sis of the Framingham study, women who were employed for more than half of their adult lives were no more likely to develop CHD than were homemakers. However, employed women with children were more likely to suffer from heart disease. In fact, the risk increased with the number of children for employed women but not for homemakers (Haynes & Feinleib, 1980). Women (and men) encounter strain not only in their occupations, but also in the competition between their various life roles.

stress and physical health CHAPTER 8 225

heart disease? Or does depression increase CHD, and if so, how? A study of over 2,400 depressed or isolated heart attack patients supports the first interpretation. A major randomized trial of cog- nitive behavior therapy, sometimes combined with antidepressant medication, alleviated depression somewhat, but the treatment group had no better coronary outcome than untreated controls (ENRICHD, 2003).

Anxiety seems to be associated with one crucial aspect of CHD: sudden cardiac death (Rozanski et al., 1999). Heart-fo- cused anxiety, preoccupation with heart and chest sensations, is another important concern (Eifert, Zvolensky, & Lejuez, 2000).

SOCIAL FACTORS IN CVD Social factors can influence the risk for CVD in many ways. Friends and family members can encour- age a healthy—or an unhealthy—lifestyle. Interpersonal conflict can create anger and hostility, which increase the risk for coronary heart disease. Economic resources, being married, and/or having a close confidant all are related to a more positive prognosis (Wil- liams et al., 1992). In fact, a spouse’s confidence in coping with heart disease predicts a patient’s increased survival over four years (Rohrbaugh et al., 2004). In one study, the more the well spouse used the pronoun “we” when talking about his or her loved one’s health, the more the heart failure patient improved in the next six months (Rohrbaugh et al., 2008). More broadly, societal values

Type A Behavior and Hostility Personality may also increase the risk for CVD, particularly the Type A behavior pattern—a competitive, hostile, time urgent, impatient, and achievement- striving style of responding to challenge. As originally identified by cardiologists Meyer Friedman and Ray Rosenman (1959), the Type A individual is a “superachiever” who, like Bob Carter, knows no obstacle to success and who may sacrifice everything for the sake of achievement (Jenkins, 1988). Type B individuals, in contrast, are more calm and content.

In 1981, the National Blood, Heart, and Lung Institute con- cluded that Type A behavior was a risk factor for CHD, indepen- dent of other risks such as diet. This official sanction stimulated a great deal of additional research, but many studies conducted since 1980 failed to support earlier findings (Rozanski et al., 1999). Increasingly it appears that hostility predicts future CHD better than other aspects of Type A behavior (Miller et al., 1996; Smith & Ruiz, 2002). A Finnish investigation found that three items reliably predicted death among men who had a history of CHD or hypertension: ease with which anger was aroused, argu- mentativeness, and irritability (Koskenvuo et al., 1988).

Depression and Anxiety Depression is three times more com- mon among patients with CHD than in the general popula- tion, and depression doubles the risk for future cardiac events (Frasure-Smith & Lespèrance, 2005). Is depression a reaction to

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226 CHAPTER 8 stress and physical health

no intervention was given in one town that was used as a control group. The media campaigns were supplemented with face-to-face interviews in one of the two towns receiving the intervention.

Findings indicated that the media campaigns increased the public’s knowledge about CHD, particularly in the commu- nity where face-to-face interviews took place. Did this increased knowledge lead to changes in behavior? The answer appears to be yes—up to a point. People in the experimental communities improved their diet and lowered their serum cholesterol, but they made only minor changes in smoking (Farquhar et al., 1977). The study could not determine whether the interventions helped re- duce the incidence of heart disease. Recall, however, that the rates of CVD have declined in Western countries as health behavior has improved. Increasing public awareness can slowly improve health behavior and eventually may lower the risk of heart disease.

SECONDARY PREVENTION The treatment of essential hyperten- sion is one of the most important attempts at the secondary preven- tion of CHD. Treatments of hypertension fall into two categories. One focuses on improving health behavior, and the other emphasizes stress management, attempts to teach more effective coping skills.

Weight reduction, decreased alcohol consumption, and re- duced intake of dietary salt all can help lower blood pressure. For many patients these behavioral changes eliminate the need for taking antihypertensive medication (Johnston, 1989). But can experts help people make the necessary lifestyle changes? Many efforts are only minimally effective, in part because they are weak or poorly constructed. For example, a physician may sim- ply encourage a patient to lose weight or give him educational pamphlets to read. More intensive treatments appear to be more effective (Dusseldorp et al., 1999).

The major form of stress management used to treat hyper- tension is behavior therapy, particularly relaxation training and

(for example, about smoking) and cultural norms (for example, about job stress) also can affect the risk for CVD.

Recognizing the importance of interpersonal and societal in- fluences, many efforts have been directed toward structuring the social ecology—the interrelations between the individual and the social world—to promote health (Stokols, 1992). As a child, you were exposed to many of these efforts, such as antismoking cam- paigns or the awards given in school for physical fitness. Good health is commonly promoted in the media, and more employ- ers also are encouraging positive health behavior. Do these broad- scale efforts work? We address this question shortly.

INTEGRATION AND ALTERNATIVE PATHWAYS CVD is an ex- cellent example of the value of the systems approach. To illustrate this, we return to our automotive analogy. Some cars are built for high performance, some for economy. Some are defective when they leave the factory. Whatever its original condition, a car’s state of repair is affected by how it is driven and how it is maintained. Similarly, CVD is caused by a combination of genetic makeup, an occasional structural defect, maintenance in the form of health behavior, and how hard the heart is driven by stress, depression, coping, and societal standards.

Much progress has been made in identifying biological, psychological, and social risk factors for CVD. An important goal for future research is to integrate knowledge across risk fac- tors (Kop, 1999). Numerous questions need to be addressed. For example, how do we distinguish the effects of stress as an immediate, precipitating cause of CHD from its cumulative ef- fects on health over long periods of time? To what extent are the risks associated with stress caused by poor health behavior and not by stress itself? What protects those individuals who do not become ill, even when they are exposed to multiple risk factors?

Prevention and Treatment of CVD Several medications known as antihypertensives are effective treat- ments for reducing high blood pressure. Other drugs, called beta blockers, reduce the risk of myocardial infarction or sudden cor- onary death following a cardiac episode (Johnston, 1989). Still other biomedical interventions reduce the risk factors associated with CVD. For example, serum cholesterol can be lowered with medication, and this reduces CVD and mortality (Taylor et al., 2011). It also may be possible to lower the risk for heart disease with psychological interventions.

PRIMARY PREVENTION Numerous efforts attempt to prevent CVD by encouraging people to quit smoking, eat well, exercise, monitor their blood pressure, and otherwise improve their health behavior. Many of these familiar efforts have not been evaluated, but researchers have conducted a handful of careful studies. One of the most important took place in three small California communi- ties near Stanford University (Farquhar et al., 1977). Media cam- paigns designed to improve knowledge and change behavior were offered in two towns that formed the experimental groups, whereas

A graphic health warning on a pack of cigarettes sold in Canada. In 2000, the Canadian government approved such warnings, the first country in the world to take such an aggressive anti-smoking stance.

stress and physical health CHAPTER 8 227

one and one-half years. Neither stress management nor any of the dietary supplements produced benefits. Findings from Phase II of the TOHP underscored the importance of weight loss. Even a modest reduction in weight produced clinically significant reduc- tions in blood pressure (Stevens et al., 2001).

The Multiple Risk Factor Intervention Trial (MRFIT), an- other major investigation, included over 12,000 men at risk for CHD. Participants were assigned at random to intervention pro- grams, including both education and social support. Treatment caused improved health behavior, specifically reduced smoking and lower serum cholesterol. However, the treatment groups did not have a lower incidence of heart disease than controls seven years later (MRFIT, 1982). An encouraging interpretation of this discouraging outcome is that men in the control group also

biofeedback. Biofeedback uses laboratory equipment to moni- tor physiological processes that generally occur outside conscious awareness and to provide the patient with conscious feedback about these processes. Blood pressure may be displayed on a video screen, for example, so that increases or decreases are readily ap- parent to the patient. The patient can then experiment with vari- ous coping strategies, for example, imagining lying on a beach, to see whether the technique reduces his or her blood pressure.

Biofeedback produces reliable reductions in blood pressure, as does relaxation training. Unfortunately, the reductions are small, often temporary, and considerably less than those produced by antihypertensive medications (Andrews et al., 1984). Over- all, stress management appears to improve quality of life but has little effect on disease (Claar & Blumenthal, 2003). Biofeedback is a particularly dubious treatment for hypertension, one that some well-respected investigators suggest should be abandoned (Johnston, 1989).

The Trials of Hypertension Prevention (TOHP) is an im- portant study of whether stress management and health behavior interventions can lower high blood pressure (TOHP Collabora- tive Research Group, 1992). More than 2,000 women and men with hypertension were randomly assigned to one of seven dif- ferent treatments, three lifestyle interventions—weight reduction, sodium (salt) reduction, and stress management—plus four nu- tritional supplement conditions. Group meetings were held over several weeks for the three lifestyle interventions. In the nutrition conditions, the patient’s ordinary diet was supplemented with di- etary agents hypothesized to lower blood pressure: calcium, mag- nesium, potassium, or fish oil. Results from Phase I of the study indicated that only the weight reduction and the salt reduction programs lowered blood pressure over a follow-up period of up to

Exercise and maintaining a healthy weight can help prevent heart disease and also lower the risk for recurrence.

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228 CHAPTER 8 stress and physical health

getting HELP

Stressed out? We all are at times—when we face exams, have to deal with difficult relationships, or just have too much to do and not enough time to do it. If there is too much stress in your life, a helpful first step is to analyze it. One great way to begin is to write about the situ- ations that stress you out, your responses, and your attempts at coping. You could start a journal; you could write someone a letter (that you may or may not mail); or you could just jot down a few notes. Writing can help you get some things off your chest—and off your mind. Writing can also help you to sort things out. Writing takes thoughts and feelings from in- side your head and puts them out there, where you can look at them. Sometimes just putting your thoughts down on paper can help: “Whew! I don’t have to think about that anymore!” Another benefit is that you can go back and read what you wrote and correct and organize your thoughts and feelings. An engaging, research-based account of the benefits of writ- ing is James Pennebaker’s Opening Up: The Healing Power of Expressing Emotions.

Another way to analyze stress in your life is to complete some stress-rating forms. You can find one commonly used form in

Table 8.1 (page 209), or you can complete a stress rating mea- sure online. A quick Internet search will pull up several sites that allow you to complete stress rating measures. Some are de- signed specifically for college students.

What about coping with stress? If your usual strategies aren’t working, a useful resource about relaxation is Herbert Benson’s book The Relaxation Response. Exercise is another healthy coping technique. If you have troubling physical symptoms linked with stress, you should consult your family physician. A mental health professional may be more appropriate to contact if your problems with stress are emotional.

Finally, if you are suffering from the stress of having a physi- cal illness and want to know about the latest research, the place to start online is the homepage of the National Insti- tutes of Health (NIH). If your illness is chronic, particularly difficult, or rare, you might find it helpful to communicate online with others who suffer from the same disease. Because there are so many resources on the Internet, most search engines contain a category specifically for “health.” As you browse, remember to be skeptical and cautious in evaluating information.

improved their health behavior. The control group had a lower disease rate than expected based on their risk indicators, and the study was conducted during a time when the public’s concern with health increased dramatically.

TERTIARY PREVENTION Tertiary prevention of CHD targets pa- tients who have already had a cardiac event, typically a myocardial infarction. The hope is to reduce the incidence of recurrence of the illness. Exercise programs are probably the most common treatment recommended for cardiac patients, but evidence of their effective- ness is limited (Johnston, 1989). The most effective programs are both structured and individualized for each patient (Blanchard, 1992; Frasure-Smith & Prince, 1985). One patient may benefit from a smoking reduction program, a second by a stress reduction workshop, and a third by exercise classes. Handing out pamphlets or delivering stern lectures does little to alter health behavior.

More optimistic evidence on preventing the recurrence of CHD comes from efforts to alter the Type A behavior pattern (Friedman et al., 1986), a somewhat surprising circumstance given the controversies about Type A. Successful intervention is multifaceted. For example, it includes role playing—improvisa- tional play acting—to teach patients how to respond to stressful interactions with reduced hostility. The cardiac patient might act out his usual response to a bothersome subordinate, for example. In subsequent role plays, the patient tries out a new, less hostile

way of responding. Cognitive therapy designed to alter faulty thought patterns also is a part of these interventions (Thoresen & Powell, 1992). For example, Bob Carter believed that he must be the best at everything. Cognitive therapy helps patients like Bob to develop beliefs and goals that are more realistic—and healthy.

Type A behavior can be modified, and this may reduce the subsequent risk for CHD (Nunes, Frank, & Kornfeld, 1987; Thoresen & Powell, 1992). One study of nearly 600 patients found that stress management training reduced the annual inci- dence of cardiac events by almost 50 percent in comparison to 300 patients who received standard medical care (Friedman et al., 1986). Importantly, subjects who showed the greatest reduc- tion in Type A behavior were four times less likely to experience a myocardial infarction during the following two years.

Finally, we should note that some treatments focus on the effects of heart disease on life stress rather than the other way around. These treatments teach cardiac patients and their families to cope more effectively with the psychological consequences of having a heart attack, including depression, anxiety, and changes in sexuality, marriage, and family relationships (Johnston, 1985). Since depression is a risk factor for future cardiac illness (Car- ney et al., 1995), such interventions may, in turn, help improve the patient’s physical health. The link between stress and physical health clearly is a reciprocal one.

stress and physical health CHAPTER 8 229

Scientists now view every physical illness as a product of the interaction between the psyche and soma, mind and body.

Behavioral medicine is a multidisciplinary field that investigates psychological factors in physical illness.

Stress is a challenging event that requires physiological, cogni- tive, or behavioral adaptation.

Stress activates the fight-or-flight response, an evolved reac- tion to threat that leads to the intense arousal of the sympa- thetic nervous system.

In response to stress, the adrenal glands release two key hor- mones, epinephrine (adrenaline), which leads to the familiar “rush of adrenaline,” and cortisol (the “stress hormone”), which helps the body make repairs similar to steroids.

Psychoneuroimmunology (PNI) is the study of how stress also impairs immune functioning.

Problem-focused coping is an attempt to change the stressor, while emotion-focused coping involves altering internal distress.

Health behavior includes positive actions like exercise and negative ones like cigarette smoking.

Lifestyle is central to the top causes of death in the United States today.

The number one killer is cardiovascular disease (CVD), disor- ders that affect the heart and circulatory system. Psychological factors contributing to CVD include health behavior, cardiovas- cular reactivity, chronic stressors like job strain, the hostility that is part of the Type A behavior pattern, and depression and anxiety.

The primary prevention of CHD includes efforts to improve health behavior. Treating hypertension by encouraging improved health behavior and stress management are efforts at the secondary prevention of CHD. Tertiary pre- vention of CHD targets patients who have already had a cardiac event, for example, attempting to modify their Type A behavior.

Summary8

8.1 How can stress make you physically ill? Cannon observed . . . that fight or flight is a maladaptive reaction to much stress in the modern world . . . (see page 211).

8.2 What are some good ways of coping with stress? People cope with stress in many ways, good and bad. Two basic strategies are problem-focused and emotion-focused coping . . . (see page 213).

8.3 What does it mean to say people are resilient? Positive psychologists . . . see pervasive human resilience, the ability to cope successfully with the challenges of life, including very stress- ful ones . . . (see page 214).

8.4 Does stress really play a role in diseases like cancer and AIDS? At first glance, cancer may seem to be a purely biological illness, but the importance of psychological factors quickly becomes apparent.

For example, health behavior such as cigarette smoking contrib- utes to exposure to various carcinogens, cancer-causing agents . . . (see page 218).

8.5 What is a “lifestyle disease”? Several health behaviors are linked to CVD . . . which is why it is called a “lifestyle disease.” . . . Obesity, a fatty diet, elevated serum cholesterol levels, heavy alcohol consumption, and lack of exercise . . . increase the risk for CHD . . . (see page 223).

8.6 What is “Type A” behavior? Can it really cause heart attacks? Characteristic styles of responding to stress may also increase the risk for CVD, particularly the Type A behavior pattern—a competitive, hostile, time-urgent, impatient, and achievement-striving style of responding to challenge . . . (see page 224).

critical thinking review

The Big Picture

230 CHAPTER 8 stress and physical health

key terms acquired immune deficiency

syndrome (AIDS) 219 behavioral medicine 207 biofeedback 227 cardiovascular disease

(CVD) 221 coronary heart disease

(CHD) 221

cortisol 211 cross-sectional study 223 emotion-focused coping 213 fight-or-flight response 211 general adaptation syndrome

(GAS) 213 health behavior 215 homeostasis 213

human immunodeficiency virus (HIV) 219

longitudinal study 223 problem-focused

coping 213 psychoneuroimmunology

(PNI) 212 resilience 214

Sleep-Wake disorders 220 stress 208 tend and befriend 211 Type A behavior pattern 225

9

personality disorders

232 CHAPTER 9 personality disorders

9 The Big Picture learning objectives

9.1 What is the difference between being eccentric

and having a personality disorder?

9.2 In what ways are borderline and narcissistic

personality disorders similar?

9.3 What are the advantages of a dimensional approach

that would describe personality problems as variations on maladaptive personality traits?

9.4 Which personality disorders are least likely

to change as a person gets older?

9.5 Why are personality disorders so difficult to treat?

9.6 What is the difference between antisocial

personality disorder and psychopathy?

People are social organisms. Reproduction and survival depend on successful, cooperative interactions with other people. We form so- cial alliances for many purposes, such as raising families, doing our jobs, and living in a community. We also compete with others, and in some cases we have to protect ourselves from others. These rela- tionships are governed by a variety of psychological mechanisms that, taken together, constitute our personalities. Personality refers to en- during patterns of thinking and behavior that define the person and distinguish him or her from other people. Included in these patterns are ways of expressing emotion as well as patterns of thinking about ourselves and other people. For the most part, personality serves as the glue that anchors and facilitates interactions with other people. But it can also go awry. When enduring patterns of behavior and emotion bring the person into repeated conflict with others, and when they prevent the person from maintaining close relationships with others, an individual’s personality may be considered disordered.

Of course, the dividing line between eccentricity and person- ality pathology is difficult to define. We all have our quirks and idiosyncrasies, and there are many different ways to manage rela- tionships with other people. For example, it is often helpful to be

skeptical of the things that other people do and say. When does a tendency to be suspicious of other people’s motives cross the line into paranoia? Self-confidence is another admirable quality, but it can lead to problems if it escalates into full-blown grandiosity. In many ways, the distinctions among healthy traits, eccentricity, and personality pathology depend on the person’s ability to adapt to the demands of different situations. Variety and flexibility in interpersonal behavior are undoubtedly helpful. People with per- sonality disorders can make their own social problems worse (of- ten unwittingly) by persistently responding in ways that do not suit the social challenges that they face.

Overview All of the personality disorders are based on exaggerated personal- ity traits that are frequently disturbing or annoying to other peo- ple. For example, in the first case study of this chapter, you will meet a young man whose consistently impulsive and deceitful be- havior brought him into repeated conflicts with other people and with legal authorities.

In order to qualify for a personality disorder diagnosis in DSM- 5, a person must fit the general definition of personality disorder (which applies to all 10 subtypes) and must also meet the specific criteria for a particular type of personality disorder. The specific cri- teria consist of a list of symptoms and behaviors that characterize the disorder. The general definition of personality disorder (PD) presented in DSM-5 emphasizes the duration of the pattern and the social impairment associated with the symptoms in question. The problems must be part of “an enduring pattern of inner experi- ence and behavior that deviates markedly from the expectations of the individual’s culture” (APA, 2013). The pattern must be evident in two or more of the following domains: cognition (such as ways of thinking about the self and other people), emotional responses, interpersonal functioning, or impulse control. This pattern of mal- adaptive experience and behavior must also be

• Inflexible and pervasive across a broad range of personal and social situations.

• The source of clinically significant distress or impairment in social, occupational, or other important areas of functioning.

• Stable and of long duration, with an onset that can be traced back at least to adolescence or early adulthood.

The concept of social dysfunction plays an important role in the definition of personality disorders. It provides a large part of the justification for defining these problems as mental disorders. If the personality characteristics identified in DSM-5 criteria sets typically interfere with the person’s ability to get along with other people and perform social roles, they become more than just a collection of eccentric behaviors or peculiar habits. They can then be viewed as a form of harmful dysfunction (Wakefield, 1999). In fact, most of the clusters of pathological personality characteristics that are described in DSM-5 do lead to impaired social functioning or occupational impairment (Ro & Clark, 2010; Skodol et al., 2007).

personality disorders CHAPTER 9 233

he was generously provided for, he stole some of his father’s chickens from time to time, selling them at stores downtown. Pieces of table silver would be missed. These were sometimes recovered from those to whom he had sold them for a pittance or swapped them for odds and ends, which seemed to hold no particular interest or value for him. He resented and seemed ea- ger to avoid punishment, but no modification in his behavior re- sulted from it. He did not seem wild or particularly impulsive, a victim of high temper or uncontrollable drives. There was noth- ing to indicate he was subject to unusually strong temptations, lured by definite plans for high adventure and exciting revolt.

He lied so plausibly and with such utter equanimity, devised such ingenious alibis, or simply denied all responsibility with such convincing appearances of candor that for many years his real ca- reer was poorly estimated.

Among typical exploits with which he is credited stand these: prankish defecation into the stringed intricacies of the school pi- ano, the removal from his uncle’s automobile of a carburetor for which he got 75 cents, and the selling of his father’s overcoat to a passing buyer of scrap materials.

At 14 or 15 years of age, having learned to drive, Tom began to steal automobiles with some regularity. Often his intention seemed less that of theft than of heedless misappropriation. A neighbor or friend of the family, going to the garage or to where the car was parked outside an office building, would find it missing. Sometimes the patient would leave the stolen vehicle within a few blocks or miles of the owner, sometimes out on the road where the gasoline had given out. After he had tried to sell a stolen car, his father con- sulted advisors and, on the theory that he might have some specific craving for automobiles, bought one for him as a therapeutic mea- sure. On one occasion while out driving, he deliberately parked his own car and, leaving it, stole an inferior model which he left slightly damaged on the outskirts of a village some miles away.

Private physicians, scoutmasters, and social workers were con- sulted. They talked and worked with him, but to no avail. Listing the deeds for which he became ever more notable does not give an adequate picture of the situation. He did not every day or every week bring attention to himself by major acts of mischief or destructiveness. He was usually polite, often considerate in small, appealing ways, and always seemed to have learned his lesson after detection and punishment. He was clever and learned easily. During intervals in which his attendance was regular, he impressed his teachers as outstanding in ability. Some charm and apparent modesty, as well as his very con- vincing way of seeming sincere and to have taken resolutions that would count, kept not only the parents but all who encountered him clinging to hope. Teachers, scoutmasters, the school principal, and others recognized that in some very important respects he differed from the ordinary bad or wayward youth. (They) made special efforts to help him and to give him new opportunities to reform or readjust.

When he drove a stolen automobile across a state line, he came in contact with federal authorities. In view of his youth and the wonderful impression he made, he was put on probation. Soon afterward he took another automobile and again left it in

Personality disorders are among the most controversial cat- egories in the diagnostic system for mental disorders (Tyrer, 2012; Verheul, 2012). They are difficult to identify reliably, they show high levels of comorbidity among themselves and with other mental disorders, and their definition has not been well- grounded in scientific knowledge regarding basic elements of personality. For all of these reasons, you should think critically about the validity of these categories.

Although they are difficult to define and measure, personal- ity disorders are also crucial concepts in the field of psychopathol- ogy. Several observations support this argument. First, personality disorders are associated with significant social and occupational impairment. They disrupt interpersonal relationships, including those involving friends and coworkers. Personality disorders also play an important role in many cases of marital discord and vio- lence (Weinstein, Gleason, & Oltmanns, 2012; Whisman, Tolejko, & Chatav, 2007). Second, the presence of pathological personality traits during adolescence is associated with an increased risk for the subsequent development of other mental disorders (Cohen et al., 2007). Negative emotionality (high neuroticism) often predicts the later onset of major depression or an anxiety disorder. Impulsivity and antisocial personality increase the person’s risk for alcoholism. Third, in some cases, personality disorders actually represent the beginning stages of the onset of a more serious form of psychopa- thology. Paranoid and schizoid personality disorders, for example, sometimes precede the onset of schizophrenic disorders. Finally, the presence of a comorbid personality disorder can interfere with the treatment of a disorder such as depression (Fournier et al., 2008).

The following cases illustrate several of the most important features of personality disorders. Our first case is an example of antisocial personality disorder, which is defined in terms of a per- vasive and persistent disregard for, and frequent violation of, the rights of other people. This 21-year-old man was described by Hervey Cleckley (1976) in his classic treatise on this topic. The man had been referred to Cleckley by his parents and his lawyer after his most recent arrest for stealing. The parents hoped that their son might avoid a long prison sentence if Cleckley decided that he was suffering from a mental disorder.

A Car Thief’s Antisocial Personality Disorder Tom looks and is in robust physical health. His manner and ap- pearance are pleasing. In his face a prospective employer would be likely to see strong indications of character as well as high in- centive and ability. He is well-informed, alert, and entirely at ease, exhibiting a confidence in himself that the observer is likely to consider amply justified. This does not look like the sort of man who will fail or flounder about in the tasks of life, but like some- one incompatible with all such thoughts.

[In childhood, Tom] appeared to be a reliable and manly fel- low but could never be counted upon to keep at any task or to give a straight account of any situation. He was frequently truant from school. No advice or persuasion [deterred] him [from] his acts, despite his excellent response in all discussions. Though

234 CHAPTER 9 personality disorders

the adjoining state. It was a very obvious situation. The conse- quences could not have been entirely overlooked by a person of his excellent shrewdness. He admitted that the considerable risks of getting caught had occurred to him but felt he had a chance to avoid detection and would take it. No unusual and powerful motive or any special aim could be brought out as an explanation.

Tom was sent to a federal institution in a distant state where a well-organized program of rehabilitation and guidance was avail- able. He soon impressed authorities at this place with his attitude and in the way he discussed his past mistakes and plans for a dif- ferent future. He seemed to merit parole status precociously and this was awarded him. It was not long before he began stealing again and thereby lost his freedom (Cleckley, 1976, pp. 64–67).

Notice that the fundamental features of Tom’s problems were clearly evident by early adolescence, and they were exhibited consistently over an extended period of time. The stable, long- standing nature of personality disorders is one of their most char- acteristic features. In this way, they are distinguished from many other forms of abnormal behavior that are episodic in nature.

This case is an excellent example of the senseless nature of the illegal and immoral acts committed by people who meet the diagnostic criteria for antisocial personality disorder. Another puzzling feature of this disorder is the person’s apparent lack of remorse and the inability to learn from experience that accompa- nies such a history of delinquent behavior. It is difficult to under- stand why someone would behave in this manner. Mental health professionals appeal to the notion of personality disorder to help them understand these irrational behaviors.

The case of Tom also illustrates some other important features of personality disorders. Most other forms of mental disorder, such as anxiety disorders and mood disorders, are ego-dystonic; that is, people with these disorders are distressed by their symptoms and uncomfortable with their situations. Personality disorders are usually ego-syntonic—the ideas or impulses with which they are associated are acceptable to the person. People with personality disorders frequently do not see themselves as being disturbed. We might also say that they do not have insight into the nature of their own problems. Tom did not believe that his repeated antiso- cial behavior represented a problem. The other people for whom he created problems were suffering, but he was not. Many forms of personality disorder are defined primarily in terms of the prob- lems that these people create for others rather than in terms of their own subjective distress (Oltmanns & Powers, 2012).

The ego-syntonic nature of many forms of personality disor- der raises important questions about the limitations of self-report measures—interviews and questionnaires—for their assessment. Many people with personality disorders are unable to view them- selves realistically and are unaware of the effect that their behavior has on others. Therefore, assessments based exclusively on self- report may have limited validity (Oltmanns & Turkheimer, 2009). They may underestimate the frequency and severity of certain © Edward Frascino/The New Yorker Collection/www.cartoonbank.com

aspects of personality pathology, particularly those problems as- sociated with narcissism. The development of alternative assess- ment methods, such as collecting information from peers, family members, or mental health professionals, remains an important challenge for future research studies (Clark, 2007).

Symptoms The specific symptoms that are used to define personality disor- ders represent maladaptive variations in several of the building blocks of personality (see Chapter 2). These include motives, cog- nitive perspectives regarding the self and others, temperament, and personality traits. We have organized our description of typi- cal symptoms around these issues, which run through the broad mixture of specific symptoms that define the 10 types of person- ality disorder included in DSM-5.

Social Motivation The concept of a motive refers to a person’s desires and goals (Emmons, 1997). Motives (either conscious or unconscious) describe the way that the person would like things to be, and they help to explain why people behave in a particular fashion. For example, a man might have neglected to return a telephone call because he wanted to be alone (rather than because he forgot that someone had called). Two of the most important motives in understanding human personality are affiliation—the desire for close relation- ships with other people—and power—the desire for impact, pres- tige, or dominance (Winter et al., 1998). Individual differences with regard to these motives have an important influence on a person’s health and adjustment.

Many of the symptoms of personality disorders can be de- scribed in terms of maladaptive variations with regard to needs for affiliation and power. One particularly important issue is the absence of motivation for affiliation. While most people enjoy spending time with other people and want to develop intimate

personality disorders CHAPTER 9 235

persistent problems in social distance (either becoming too inti- mate or maintaining too much distance from others). Finally, an- other important element of interpersonal perception is the ability to empathize with others—to anticipate and decipher their emo- tional reactions and use that knowledge to guide our own behav- ior. Deficits in the ability to understand the emotions of other people represent one of the core features of personality disorders.

Temperament and Personality Traits If motivation helps to explain why people behave in certain ways, temperament and personality traits describe how they behave. Temperament refers to a person’s most basic, characteristic styles of relating to the world, especially those styles that are evident during the first year of life (Caspi & Shiner, 2008; Mervielde et al., 2005). Definitions of temperament typically include dimensions such as activity level and emotional reactivity (see Chapter 2). These factors vary considerably in level or degree from one infant to the next and have important implications for later development, such as social and academic adjustment when the child eventually enters school. For example, children who demonstrate a lack of control when they are very young are much more likely than their peers to experience problems with hyperactivity, distractibility, and conduct disorder when they are adolescents (Caspi et al., 1995). Young children who are extremely shy are more likely to be anxious and socially inhib- ited in subsequent years (Eisenberg et al., 1998; see Chapter 16).

Experts disagree about the basic dimensions of temperament and personality. Some theories are relatively simple, using only three or four dimensions. Others are more complicated and con- sider as many as 30 or 40 traits. One point of view that has come to be widely accepted is known as the five-factor model (FFM) of personality (McCrae & Costa, 2013). The basic traits (also known as domains) included in this model have already been summarized in Chapter 2. They are neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. Each of the five principal domains can be subdivided into six

relationships with friends and family members, some people do not. They prefer isolation. Severely diminished or absent motiva- tion for social relationships is one pervasive theme that serves to define certain kinds of personality disorder.

Exaggerated motivation for power (and achievement) also contributes to the picture that describes personality disorders. For example, some people are preoccupied with a need for ad- miration and the praise of others. They think of themselves as privileged people and insist on special treatment. In some cases, excessive devotion to work and professional accomplishment can lead a person to ignore friends and family members as well as the pursuit of leisure activities. This lack of balance can have a serious disruptive effect on the person’s social adjustment.

Cognitive Perspectives Regarding Self and Others Our social world also depends on mental processes that deter- mine knowledge of ourselves and other people (Baumeister, 1997; Kihlstrom & Hastie, 1997). Distortions of these mechanisms are associated with personality disorders. For example, one central issue involves our image of ourselves. When you are able to maintain a realistic and stable image of yourself, you can plan, negotiate, and evaluate your relationships with other people. Knowing (and hav- ing confidence in) your own values and opinions is a necessary pre- requisite for making independent decisions without the assistance or reassurance of others. Self-image is also intimately connected to mood states. If you vacillate back and forth between unrealistically positive and negative views of yourself, your mood will swing dra- matically. You may also need constant reassurance from others and be too dependent on their opinions as a means of maintaining your own self-esteem. We have to be able to evaluate our own importance. Of course, it’s useful to think of yourself in positive terms (and many maintain a positive “halo”), but extreme grandiosity can be disrup- tive. Perhaps even more damaging is a pattern in which people see themselves as socially inept or inferior to other people.

When we misperceive the intentions and motives and abilities of other people, our relationships can be severely disturbed. Para- noid beliefs are one example. Some people believe, without good reason, that other people are exploiting, deceiving, or otherwise trying to harm them. Unreasonable fears of being abandoned, criticized, or rejected are also examples of distorted perception of others’ intentions. Working effectively in a group of people also requires realistic appraisal of the talents and abilities of others. In order to cooperate with other people, we must be able to appreci- ate their competence. People with personality disorders run into problems because they misperceive other people in many different ways (as being either threatening, or uncaring, or incompetent).

Many elements of social interaction also depend on being able to evaluate the nature of our relationships with other people and then to make accurate judgments about appropriate and inap- propriate behaviors. A successful relationship with a sexual partner involves knowing when intimacy is expected and when it should be avoided. Some people with personality disorders experience

Individual differences in childhood temperament, such as emotional reactivity and self-regulation, predict personality characteristics in adulthood.

236 CHAPTER 9 personality disorders

McCrae, 2013). Problems may arise in association with extreme variations in either direction (high or low). Dramatically elevated levels of anger–hostility, impulsiveness, and excitement seeking are particularly important, as are extremely low levels of trust, compli- ance, and tender-mindedness. Although some forms of personality

more specific elements or facets (see Table 9.1). Taken as a whole, the five-factor model provides a relatively comprehensive descrip- tion of any person’s behavior.

Many personality disorders are defined in terms of maladaptive variations on the kinds of traits listed in Table 9.1 (Widiger, Costa, &

table 9.1 Domains and Facets of the Five-Factor Model of Personality

People with High Scores Are People with Low Scores Are

Neuroticism

Anxiety extremely nervous lacking appropriate anxiety

Anger–Hostility hypersensitive; easily angered unable to express anger

Depression continually depressed unable to appreciate losses

Self-consciousness very easily embarrassed indifferent to opinions of others

Impulsiveness extremely impulsive restrained or restricted; dull

Vulnerability easily overwhelmed by stress oblivious to danger

Extraversion

Warmth inappropriately affectionate unable to develop intimate relations

Gregariousness unable to tolerate being alone socially isolated

Assertiveness domineering, pushy resigned and ineffective

Activity driven, frantic, distractible sedentary and passive

Excitement-seeking reckless, careless dull, monotonous

Positive Emotions giddy, lose control of emotions solemn, unable to enjoy things

Openness to Experience

Fantasy preoccupied with daydreams unimaginative

Aesthetics obsessed with unusual interests don’t appreciate culture or art

Feelings governed by strong emotionality seldom have strong feelings

Actions unpredictable avoid change, stick to routine

Ideas preoccupied with strange ideas reject new ideas

Values lack guiding belief systems dogmatic and closed-minded

Agreeableness

Trust gullible paranoid and suspicious

Straightforwardness too self-disclosing dishonest and manipulative

Altruism often exploited or victimized lacking regard for rights of others

Compliance acquiescent, docile, submissive argumentative, defiant

Modesty meek and self-denigrating conceited, arrogant, pompous

Tender-mindedness overwhelmed by others’ pain callous, coldhearted, ruthless

Conscientiousness

Competence overly perfectionistic lax, incapable of work

Order preoccupied with rules, order disorganized, sloppy

Dutifulness places duty above morality not dependable, unreliable

Achievement-striving workaholic aimless, no clear goals

Self-discipline single-minded pursuit of goals hedonistic, self-indulgent

Deliberation ruminate to excess careless making decisions

Source: Adapted from T.A. Widiger, P.T. Costa, Jr., and R.R. McCrae, 2002, “A proposal for Axis II: Diagnosing Personality Disorders Using teh Five-Factor Model,” in P.T. Costa, Jr., and T.A. Widiger, Eds., Personality Disorders and the Five-Factor Model of Personality, 2nd ed, pp. 431-456. Washington, DC: American Psychological Association.

personality disorders CHAPTER 9 237

trait. Again, this might have been a valuable adaptive skill if Tom had been an espionage agent. The meanings that are assigned to particu- lar traits depend on the environment in which they are observed.

Diagnosis DSM-5 includes two different approaches to the classification of personality disorders. The main body of the manual describes the traditional, categorical approach. Each of 10 specific types of personality disorder is defined by a set of characteristic symp- toms. People who meet the general criteria for a personality disorder and who also exhibit enough symptoms to pass the di- agnostic threshold for a specific type of disorder would qualify for a diagnosis. Those who do not meet this somewhat arbitrary threshold do not have a disorder, according to this perspective. We will refer to this approach as the categorical definition of per- sonality disorders.

The workgroup charged with revising the classification of personality disorders proposed a dramatic change for DSM-5. Their proposal emphasized the description of maladaptive per- sonality traits using a set of 25 dimensional scales. We will refer to this approach as the dimensional definition of personality disorders, and it will be described later in this chapter. The new dimensional definition was ultimately rejected, but it is included in Sec- tion III of the manual, along with other conditions that require further consideration (see Thinking Critically about DSM-5 on page 243). For now, the categorical model remains the official DSM-5 approach to defining personality disorders.

The DSM-5 categorical system for personality disorders includes 10 types that are organized into three clusters on the basis of broadly defined characteristics. Specific disorders in each cluster are listed in Table 9.2. In the following pages we give brief descriptions of these personality disorder types. These

disorder are associated with high levels of anxiousness and vulner- ability, people with antisocial personality disorder frequently exhibit unusually low levels of anxiety and concern about danger. We return to these dimensions in the next section of this chapter.

Context and Personality Two important qualifications must be made about the develop- ment and persistence of individual differences in temperament and personality. First, these differences may not be evident in all situa- tions. Some important personality features may be expressed only under certain challenging circumstances that require or facilitate a particular response (Eaton, South, & Krueger, 2009). For example, Tom did not always appear to be impulsive and irresponsible. He was usually polite when he was with adults, and he went through intervals in which he followed rules and attended school regularly.

The second qualification involves the consequences of exhib- iting particular traits. Social circumstances frequently determine whether a specific pattern of behavior will be assigned a positive or negative meaning by other people. Difficult temperament, for ex- ample, may serve an adaptive function when it is beneficial for an infant to be demanding and highly visible—for example, during a famine or while living in a large institution. On the other hand, in some circumstances, difficult temperament can be associated with an increased risk for certain psychiatric and learning disorders.

Consider the traits that Tom exhibited, especially impulsiv- ity and lack of fear. These characteristics might be maladaptive under normal circumstances, but they could be useful—indeed, admirable—in certain extraordinary settings. War is one extreme example. People in combat situations have to act quickly and deci- sively, often at great risk to their own physical health. A disregard for personal safety might be adaptive under these circumstances. Tom’s ability to lie in a calm and convincing fashion was another interesting

table 9.2 Personality Disorders Listed in DSM-5 Cluster A Includes People Who Often Appear Odd or Eccentric

Paranoid Distrust and suspiciousness of others.

Schizoid Detachment from social relationships and restricted range of expression of emotions.

Schizotypal Discomfort with close relationships, cognitive and perceptual distortions, eccentricities of behavior.

Cluster B Includes People Who Often Appear Dramatic, Emotional, or Erratic

Antisocial Disregard for and frequent violation of the rights of others.

Borderline Instability of interpersonal relationships, self-image, emotions, and control over impulses.

Histrionic Excessive emotionality and attention seeking.

Narcissistic Grandiosity, need for admiration, and lack of empathy.

Cluster C Includes People Who Often Appear Anxious or Fearful

Avoidant Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

Dependent Excessive need to be taken care of, leading to submissive and clinging behavior.

Obsessive–Compulsive Preoccupation with orderliness and perfectionism at the expense of flexibility.

Source: Courtesy of Thomas F. Oltmanns and Robert E. Emery, based on the DSM-5.

238 CHAPTER 9 personality disorders

Paranoid personality disorder is characterized by the per- vasive tendency to be inappropriately suspicious of other people’s motives and behaviors. People who fit the description for this disorder are constantly on guard. They expect that other people are trying to harm them, and they take extraordinary precau- tions to avoid being exploited or injured. Although we can all benefit from being cautious and skeptical, paranoid thinking is much more than that. The pattern is so stable and wide-ranging that it interferes with the person’s social and occupational adjust- ment. People who are paranoid are completely inflexible in the way that they view the motives of other people, and they are unable to choose situations in which they can trust other people (see Critical Thinking Matters).

Because paranoid people do not trust anyone, they have trouble maintaining relationships with friends and family mem- bers. They frequently overreact in response to minor or ambigu- ous events to which they attribute hidden meaning. When they overreact, people with paranoid personality disorder often behave aggressively or antagonistically. These actions can easily create

descriptions provide an overview that will be useful when we review the epidemiology of personality disorders. Later in the chapter we describe in considerably more detail three disor- ders that are clinically important and have been studied most extensively: schizotypal, borderline, and antisocial personality disorders.

Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders Cluster A includes three disorders: paranoid, schizoid, and schizotypal forms of personality disorder. The behavior of peo- ple who fit the subtypes in this cluster is typically odd, eccentric, or asocial. All three types share similarity with the symptoms of schizophrenia (see Chapter 13). One implicit assumption in the DSM-5 system is that these types of personality disorders may represent behavioral traits or interpersonal styles that precede the onset of full-blown psychosis. Because of their close association with schizophrenia, they are sometimes called schizophrenia spec- trum disorders.

CriTiCal Thinking matters

Can Personality Disorders Be Adaptive?

Andrew Grove, former chairman of the board of Intel Corporation, has written a popular book about business management titled Only the Paranoid Survive. He argues that successful corporate leaders must be vigilant; they have to anticipate negative events in the business world as well as future problems with their competitors. Grove’s title raises an interest- ing point about the nature of personality disorders. Their defini- tion does reflect a tension between adaptive personality traits and more extreme, maladaptive ways of thinking about oneself and other people. It can be useful to be suspicious, vigilant, skeptical, or even jealous (in some circumstances), but we should not confuse these traits with paranoid thought. By promoting an informal and misleading use of the word paranoia, Grove’s title does the field of psychopathology a disservice. In order to make progress toward understanding the nature of mental disorders, we have to be precise in our use of terms.

How can we distinguish between a cautious approach to the motives of other people and pathological paranoia? The differ- ence depends, in part, on emotional reactions—such as irrita- bility and hostility—that are associated with chronic suspicion and vigilance (Frances et al., 1995). Because they believe that others are causing problems for them, paranoid people are an- gry ( Clifton, Turkheimer, & Oltmanns, 2004). Paranoid people can also become anxious and withdrawn. Their fear is based on the conviction that others intend to cause them harm, and they try to protect themselves by avoiding other people. The

exaggerated negative emotions that accompany paranoid think- ing are not likely to foster survival in the business world or in other social circumstances.

Another way to distinguish between normal suspicions and para- noia involves the amount of time that the person spends thinking about threats posed by other people. While most people be- come suspicious from time to time, paranoid people are preoc- cupied with the notion that others are out to get them. They are unable to think otherwise (Shapiro, 1965). Paranoid people are also impaired in their ability to consider information from another person’s point of view. Most of us are able to seek and consider another person’s perception or interpretation of uncertain events; paranoid people cannot. For all of these reasons, paranoia will promote failure rather than survival in the business world.

One of the most important elements of critical thinking involves the careful definition of terms. Sloppy talk leads to sloppy think- ing. People who suggest that “a little paranoia can be useful” or “only the paranoid survive” are engaging in a misleading use of terms. It is clearly useful to be skeptical and cautious when considering the motives of other people. But the rigid and mal- adaptive patterns of thought that are characteristic of paranoid personality disorder are clearly pathological. The failure to ap- preciate the complexity and extent of these phenomena repre- sents a distraction from, rather than a contribution to, serious scholarship.

personality disorders CHAPTER 9 239

Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders Cluster B includes antisocial, borderline, histrionic, and narcissis- tic personality disorders. According to DSM-5, these disorders are characterized by dramatic, emotional, or erratic behavior, and all are associated with marked difficulty in sustaining interpersonal relationships. The rationale for grouping these disorders together is less compelling than that for Cluster A. In particular, antisocial personality disorder clearly involves something more than just a dramatic style or erratic behavior.

Antisocial personality disorder is defined in terms of a persistent pattern of irresponsible and antisocial behavior that begins during childhood or adolescence and continues into the adult years. The case study of Tom, with which we opened this chapter, illustrates this pattern of behavior. The DSM-5 defini- tion is based on features that, beginning in childhood, indicate a pervasive pattern of disregard for, and violation of, the rights of others. Once the person has become an adult, these difficul- ties include persistent failure to perform responsibilities that are associated with occupational and family roles. Conflict with oth- ers, including physical fights, is also common. These people are irritable and aggressive with their spouses and children as well as with people outside the home. They are impulsive, reckless, and irresponsible.

We have all read newspaper accounts of famous examples of antisocial personality disorder. These often include people who have committed horrendous acts of violence against other people, including genocidal war crimes and serial murders. You

a self-fulfilling prophesy. In other words, thinking (incorrectly) that he or she is being attacked by others, the paranoid person strikes. The other person is, naturally, surprised, annoyed, and perhaps frightened by this behavior and begins to treat the para- noid person with concern and caution. This response serves to confirm the original suspicions of the paranoid individual, who does not comprehend how his or her own behavior affects others.

Paranoid personality disorder must be distinguished from psychotic disorders, such as schizophrenia and delusional disor- der. The pervasive suspicions of people with paranoid personal- ity disorder do not reach delusional proportions. In other words, they are not sufficiently severe to be considered obviously false and clearly preposterous. In actual practice, this distinction is sometimes quite subtle and difficult to make.

Schizoid personality disorder is defined in terms of a per- vasive pattern of indifference to other people, coupled with a di- minished range of emotional experience and expression. These people are loners; they prefer social isolation to interactions with friends or family. Other people see them as being cold and aloof. By their own report, they do not experience strong subjective emotions, such as sadness, anger, or happiness.

Schizotypal personality disorder centers around peculiar pat- terns of behavior rather than on the emotional restriction and social withdrawal that are associated with schizoid personality disorder. Many of these peculiar behaviors take the form of perceptual and cognitive disturbance. People with this disorder may report bizarre fantasies and unusual perceptual experiences. Their speech may be slightly difficult to follow because they use words in an odd way or because they express themselves in a vague or disjointed manner. Their affective expressions may be constricted in range, as in schiz- oid personality disorder, or they may be silly and inappropriate.

In spite of their odd or unusual behaviors, people with schizotypal personality disorder are not psychotic or out of touch with reality. Their bizarre fantasies are not delusional, and their unusual perceptual experiences are not sufficiently real or com- pelling to be considered hallucinations.

Ted Bundy was executed in 1989 for killing at least 22 women. He was charming, intelligent, and self-assured.

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240 CHAPTER 9 personality disorders

down, only to then call her mother back half an hour later to apologize.

During the time I worked with Beatrice, her most noticeable personality traits were those of anger, argumentativeness, scorn- fulness, irritability, and vanity. Her intensity and demandingness made her troublesome in her family; her parents and siblings were mostly good-natured and got on well when she was not in their midst (Stone, 1993, pp. 250–251).

Histrionic personality disorder is characterized by a per- vasive pattern of excessive emotionality and attention seeking behavior. People with this disorder thrive on being the center of attention. They want the spotlight on them at all times. They are self-centered, vain, and demanding, and they constantly seek approval from others. When interacting with other people, their behavior is often inappropriately sexually seductive or pro- vocative. Their emotions tend to be shallow and may vacillate erratically. They frequently react to situations with inappropriate exaggeration.

The concept of histrionic personality disorder overlaps exten- sively with other types of personality disorders, especially border- line personality disorder. People with both disorders are intensely emotional and manipulative. Unlike people with borderline per- sonality disorder, however, people with histrionic personality dis- order have an essentially intact sense of their own identity and a better capacity for stable relationships with other people.

The essential feature of narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration, and in- ability to empathize with other people. Narcissistic people have

should not be misled, however, into thinking that only serious criminals meet the criteria for this disorder. Many other forms of persistently callous and exploitative behavior could lead to this diagnosis.

Borderline personality disorder is a diffuse category whose essential feature is a pervasive pattern of instability in mood and interpersonal relationships. People with this disorder find it very difficult to be alone. They form intense, unstable relationships with other people and are often seen by oth- ers as being manipulative. Their mood may shift rapidly and inexplicably from depression to anger to anxiety over a pattern of several hours. Intense anger is common and may be accom- panied by temper tantrums, physical assault, or suicidal threats and gestures.

Many clinicians consider identity disturbance to be the diagnostic hallmark of borderline personality disorder. People with this disturbance presumably have great difficulty main- taining an integrated image of themselves that simultaneously incorporates their positive and negative features. Therefore, they alternate between thinking of themselves in unrealistically positive terms and then unrealistically negative terms at dif- ferent moments in time. When they are focused on their own negative features, they have a deflated view of themselves and may become seriously depressed. They frequently express uncer- tainty about such issues as personal values, sexual preferences, and career alternatives. Chronic feelings of emptiness and bore- dom may also be present.

Borderline Personality Disorder A single woman of 35 had worked with four (therapists) over a pe- riod of 11 years, before the last of these referred her to me. Since Beatrice had graduated from college at age 22, she had seemed to circulate in a holding pattern. She saw herself as an executive- to-be in the corporate world but in actuality had held just a few entry-level jobs, and those only briefly. Once or twice she quit in a huff because the job, as she said, was “not interesting enough” or because “they weren’t promoting me fast enough.” She had no distinct career goals, nor had she taken any special courses to prepare herself for some particular path. The work problem did not pose a threat to her well-being, since she lived off a large trust fund that her family had set up for her.

On the relational side her situation was not much better. Bea- trice had never been “serious” with anyone and had little interest in men apart from their ability to pay compliments on her appear- ance. Her self-image was contradictory: She alternated between seeing herself as “model pretty” or else ugly. While buying an ice cream, she would feel devastated if the counterman did not make eyes at her; if he did, she would feel “insulted.”

She had no hobbies or sustaining interests and found eve- nings with nothing to do intolerable. On such evenings she would usually engage her mother in long phone conversations (her par- ents lived in a different city), demanding that her mother come and visit. If this were not possible, she would slam the phone

Since 1981, this successful artist has painted more than 1,500 self- portraits. He says he will never paint anything other than his own image because it is the only subject that holds his interest. Self-absorption is one central feature of narcissistic personality disorder.

personality disorders CHAPTER 9 241

reassurance. Often unable to make everyday decisions on their own, they feel anxious and helpless when they are alone. Like people with avoidant personality disorder, they are easily hurt by criticism, extremely sensitive to disapproval, and lacking in self- confidence. One difference between avoidant and depen- dent personality disorders involves the point in a relationship at which they experience the most difficulty. People who are avoidant have trouble initiating a relationship (because they are fearful). People who are dependent have trouble being alone or separating from other people with whom they already have a close relationship. For example, a person with dependent per- sonality disorder might be extremely reluctant to leave home in order to attend college.

Obsessive–compulsive personality disorder (OCPD) is defined by a pervasive pattern of orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. People with this disorder set ambitious standards for their own performance that frequently are so high as to be unattainable. Many would be described as workaholics. In other words, they are so devoted to work that they ignore friends, family members, and leisure activities. They are so preoccupied with details and rules that they lose sight of the main point of an activity or project. Intellectual endeavors are favored over feelings and emotional experience. These people are excessively conscien- tious, moralistic, and judgmental, and they tend to be intolerant of emotional behavior in other people.

The central features of this disorder may involve a marked need for control and lack of tolerance for uncertainty (Gibbs, South, & Oltmanns, 2003). At modest levels, these traits can represent an adaptive coping style, particularly in the face of the demands of our complex, technological society. Very high levels of these characteristics begin to interfere with a person’s social and occupational adjustment. For example, people with OCPD find it difficult to delegate responsibilities to others, and their perfec- tionism makes it extremely difficult for them to finish projects within established deadlines.

Obsessive–compulsive personality disorder should not be confused with obsessive–compulsive disorder (OCD) (see Chapter 6). A pattern of intrusive, unwanted thoughts accompa- nied by ritualistic behaviors is used to define OCD. The defini- tion of obsessive–compulsive personality disorder, in contrast, is concerned with personality traits, such as excessively high levels of conscientiousness.

A Dimensional Perspective on Personality Disorders The diagnostic manual has always treated personality disorders as discrete categories, and it has assumed that there are sharp boundaries between normal and abnormal personalities. In fact, there are a lot of people with serious personality problems who do not fit the traditional diagnostic types. The categorical approach to diagnosis forces clinicians to employ an arbitrary threshold

a greatly exaggerated sense of their own importance. They are preoccupied with their own achievements and abilities. Because they consider themselves to be very special, they cannot empa- thize with the feelings of other people and are often seen as being arrogant or haughty.

There is a considerable amount of overlap between narcissis- tic personality disorder and borderline personality disorder. Both types of people feel that other people should recognize their needs and do special favors for them. They may also react with anger if they are criticized. The distinction between these disorders hinges on the inflated sense of self-importance that is found in narcis- sistic personality disorder and the deflated or devalued sense of self found in borderline personality disorder (Ronningstam & Gunderson, 1991).

Cluster C: Avoidant, Dependent, and Obsessive–Compulsive Personality Disorders Cluster C includes avoidant, dependent, and obsessive–compul- sive personality disorders. The common element in all three dis- orders is presumably anxiety or fearfulness. This description fits most easily with the avoidant and dependent types. In contrast, obsessive–compulsive personality disorder is more accurately described in terms of preoccupation with rules and with lack of emotional warmth than in terms of anxiety.

Avoidant personality disorder is characterized by a perva- sive pattern of social discomfort, fear of negative evaluation, and timidity. People with this disorder tend to be socially isolated when outside their own family circle because they are afraid of criticism. Unlike people with schizoid personality disorder, they want to be liked by others, but they are extremely shy—easily hurt by even minimal signs of disapproval from other people. Thus they avoid social and occupational activities that require significant contact with other people.

Avoidant personality disorder is often indistinguishable from social anxiety disorder (see Chapter 6). In fact, some experts have argued that they are probably two different ways of defining the same condition (Frances et al., 1995). Others have argued that people with avoidant personality disorder have more trouble than people with social anxiety disorder in relating to other people (Millon & Martinez, 1995; Rodebaugh et al., 2010). People with avoidant personality disorder are presumably more socially with- drawn and have very few close relationships because they are so shy. People with social anxiety disorder may have a lot of friends, but they are afraid of performing in front of them or being judged by them. This distinction is relatively clear when social anxiety is defined narrowly in terms of a particular kind of situation, such as public speaking. It is much more difficult to make if the per- son’s social anxiety becomes more generalized.

The essential feature of dependent personality disorder is a pervasive pattern of submissive and clinging behavior. People with this disorder are afraid of separating from other people on whom they are dependent for advice and

242 CHAPTER 9 personality disorders

and intimacy). Problems identified in these areas serve as general markers for the presence of a personality disorder; it is the key de- cision point in deciding whether to assign a diagnosis. This judg- ment replaces the categorical model’s general criteria for PDs, which are often ignored and have been criticized for being vague and unreliable. In fact, many experts have argued that the most important consideration regarding assessment of personality pa- thology is overall level of severity rather than specific types of PDs (Tyrer et al., 2011). The dimensional system for rating level of personality functioning is relatively straightforward, and it might be efficient and effective in that role.

The second step in the proposed dimensional process speci- fies the nature or form of the disorder using ratings of pathologi- cal personality traits. What kind of personality problem does the person exhibit? The organization of these traits generally follows the FFM, but the broad domains are labeled in a way that em- phasizes the maladaptive nature of characteristics associated with PDs (Krueger et al., 2011). For example, the domain known as agreeableness in the FFM is called antagonism in the new model. More specific facets are included under each of these domains (e.g., manipulativeness, deceitfulness, grandiosity, callousness, and hostility are listed under antagonism). These traits are listed in Table 9.3 on page 244. Altogether, the proposed system in- cludes consideration of 25 core traits. You may find it useful to compare the list of FFM traits in Table 9.1 with the maladaptive traits for DSM-5 in Table 9.3. Some of the traits in Table 9.3 are taken directly from the FFM (e.g., depressivity, anxiousness, and hostility). For others, the workgroup used a trait or personal- ity dimension from the FFM and changed its name to empha- size the maladaptive end of the continuum (e.g., trust becomes suspiciousness, gregariousness becomes withdrawal, and modesty becomes grandiosity). The traits listed under psychoticism (e.g., perceptual dysregulation) are less clearly derived from the FFM and were added to the new dimensional system to provide cov- erage for schizotypal PD. The clinician’s task involves selecting and rating the traits in this list that best describe the nature of the personality problems that are related to the person’s impaired personal and social functioning.

The dimensional model places primary emphasis on ratings of the maladaptive traits, but it also retains six of the 10 specific types of PD from the categorical model. These types are listed in Table 9.3, which also identifies specific traits that are associ- ated with each of them. Traits replace diagnostic criteria for each PD in the categorical system. By including some of the types, the dimensional system retains some continuity with the categori- cal system, which mental health professionals already know. The types may provide a useful shorthand in communicating with other professionals and in conceptualizing certain kinds of prob- lems because they bring to mind familiar or prototypical combi- nations of several maladaptive traits.

Other forms of PD will be identified in the dimensional sys- tem using a new diagnosis called Personality Disorder Trait Spec- ified (PDTS). In order to qualify for this diagnosis, the person

that has been set to distinguish between normal and abnormal personality types.

Another frequent complaint about the description of per- sonality disorders is the considerable overlap among categories. Many patients meet the criteria for more than one type (Grant et al., 2005). It is cumbersome to list multiple diagnoses, especially when the clinician is already asked to consider such a broad range of other mental disorders. In fact, many clinicians are reluctant to diagnose more than one personality disorder; consequently, much information is frequently left out.

For these reasons, many experts have long favored the devel- opment of an alternative classification system for PDs, one that would be based on a dimensional view of personality pathology and also grounded in extensive research on the basic elements of personality (Widiger, Costa, & McCrae, 2013). A dimensional system based on specific personality traits could provide a more complete description of each person, and it would be more use- ful with patients who fall on the boundaries between, or present combinations of, different types of personality disorders.

The workgroup that was charged with revising the classifica- tion of personality disorders for DSM-5 proposed a model that represents a substantial change from the system that was included in DSM-IV (Skodol et al., 2011). Their proposal, which we call the dimensional PD model, was ultimately rejected in favor of retaining the traditional categorical model (see Thinking Criti- cally About DSM-5). Nevertheless, the dimensional PD model is listed in Section III of DSM-5, and many experts believe that it will eventually replace the categorical PD model, after it has been studied more extensively.

According to the PD workgroup’s proposal, the diagnosis of personality disorders is based on a two-part process. First, the clinician is asked to make a judgment regarding impairment in personality functioning as defined by problems with the person’s view of self and others (identity and self-direction) as well as dif- ficulties with maintaining interpersonal relationships (empathy

Anger and hostility are frequently associated with several forms of personality disorder, including paranoid, antisocial, borderline, and narcissistic PDs.

personality disorders CHAPTER 9 243

Notice that the trait descriptors actually help explain the overlap or co-morbidity that has been observed for many of the PD types. One example involves borderline and antisocial PD. Many people qualify for a diagnosis of both disorders using the categorical system. Table 9.3 shows clearly that the borderline and antisocial types share several maladaptive traits involving an- tagonism (e.g., hostility) and disinhibition (impulsivity). It also shows, however, that borderline and antisocial PD types are most clearly distinguished by the fact that people with borderline PD are also high on traits involving negative affectivity (e.g., emo- tional lability, anxiousness, and depressivity). Again, the relative simplicity of the trait-based approach offers an advantage over the categorical approach.

must exhibit significant impairment in self or interpersonal functioning as well as one or more pathological personality traits. This system replaces four of the categorical types with simplified trait ratings. Paranoid PD, for example, would be described by a high rating on suspiciousness, histrionic PD would be described by a high rating on attention seeking, and dependent PD would be described by a high rating on submissiveness. This system makes it easier to describe problems exhibited by people with a variety of maladaptive traits because it avoids the need to as- sign more than one type of PD diagnosis. Furthermore, people who exhibit a few symptoms that would be below the diagnostic threshold in the categorical system are easily described with one set of ratings.

Thinking CriTiCally about DSM-5

Is a Dimensional Model Too Complicated?

All of the workgroups that produced sections of DSM-5 were encouraged to think beyond the framework of the previous version of the manual. None of the workgroups pushed the limits of the system harder than the committee that tackled personality disorders. They proposed a dramatically dif- ferent approach to the classification of personality disorder. Some considered their efforts heroic. After years of debate about the relative merits of categorical and dimensional approaches to personality disorders, the field remains divided. In the end, the Board of Trustees of the American Psychiatric Associated rejected the new proposal, voting to keep the categorical approach as the official system in DSM-5. They also placed the new dimensional system in Section III of the manual where it could receive further consideration. This is the only set of disorders in DSM-5 where two different approaches to classification are both included (though one is clearly given priority over the other). If scientific data cannot resolve an issue, politics still matter in the world of psychopathology.

The dimensional system offers many attractive features, in- cluding the fact that it explicitly recognizes the continuous na- ture of these phenomena and resolves problems of excessive comorbidity. Who would object to such careful a thoughtful plan? Almost everyone! In fact, the proposal received criti- cism from every conceivable direction. Some people thought it went too far, placing less emphasis on traditional diagnostic constructs, especially borderline PD, and losing contact with years of knowledge gained in scientific research and clini- cal experience with patients who meet the criteria for these disorders (Gunderson, 2010). Others thought it didn’t go far enough. One leading member of the workgroup resigned, taking the radical position that there is no evidence to support the validity of the PD types (Livesley, 2012). Another resigned because adequate scientific support was not yet available to justify discarding the traditional categorical approach

(Verheul, 2012), and several influential experts agreed with him (Zimmerman, 2012).

Almost everyone believed that the proposal was too complex. One of the practical problems with dimensional systems is that they can be hard to use. That impression is even stronger if you are already familiar with a different system. For example, after reading our description of the 10 PD types, which are often labeled with familiar terms such as paranoid, narcissistic, and dependent, you may find the material in Table 9.3 rather com- plicated. Many of the terms used to describe the maladaptive traits are less familiar, and that is especially true for clinicians who have already been trained to use the categorical approach. Furthermore, the intellectual appeal of the dimensional ap- proach may be somewhat misleading when we consider the way in which such a system must be used in clinical practice. Therapists ultimately need to make certain important decisions that are fundamentally categorical in nature, such as whether or not a person needs treatment and whether or not that treatment should be reimbursed financially.

Is it a serious problem to have two competing systems for the classification of personality disorders? Not really, as long as one is recognized as the official system for use in clinical practice. Both have advantages and disadvantages, and both will continue to be evaluated empirically. As we pointed out in Chapter 2, classification systems are not right or wrong; they are simply more or less useful. The controversy surrounding categorical and dimensional approaches to defining PDs provides a good example of the rationale for switching from Roman numerals to Arabic numbers to label DSM-5. Presumably, the manual will be revised more frequently than in the past, with new editions be- ing numbered like new apps for your phone (DSM-5.1, DSM-5.2, and so on). Many leading experts hope that research will soon favor a formal switch, with the dimensional model being moved into the main body of the manual. Time will tell.

244 CHAPTER 9 personality disorders

at work and recurring bouts of depression. [She] reported a long history of banking jobs in which she had experienced interpersonal discord. Shortly before her entrance into treatment, Patricia was demoted from a supervisory capacity at her current job because of her inability to interact effectively with those she was supposed to supervise. She described herself as always feeling out of place with her coworkers and indicated that most of them failed to

An example of a description of a personality disorder based on the dimensional approach to PDs is provided in the following brief case study.

Narcissism from the Perspective of DSM-5 Patricia was a 41-year-old married woman who presented at an out- patient mental health clinic complaining of interpersonal difficulties

table 9.3 Maladaptive Personality Traits in the DSM-5 Dimensional Model of Personality Disorders.

TRAITS TYPES OF PERSONALITY DISORDER

Schizotypal Borderline Antisocial Narcissistic Avoidant OCPD

NEGATIVE AFFECTIVITY

Emotional lability ✕

Anxiousness ✕ ✕

Separation insecurity ✕

Submissiveness*

Perseveration ✕

Depressivity ✕

DETACHMENT

Withdrawal ✕ ✕

Intimacy avoidance ✕ ✕

Anhedonia ✕

Restricted affectivity ✕ ✕

Suspiciousness ✕

ANTAGONISM

Manipulativeness ✕

Deceitfulness ✕

Grandiosity ✕

Attention seeking ✕

Callousness ✕

Hostility ✕ ✕

DISINHIBITION

Irresponsibility ✕

Impulsivity ✕ ✕

Distractibility

Risk taking ✕ ✕

Rigid perfectionism (lack of) ✕

PSYCHOTICISM

Unusual beliefs and experiences ✕

Eccentricity ✕

Cognitive and perceptual dysregulation

✕

*Dependent PD, from DSM-IV, is not included as a PD type in the DSM-5 dimensional model. It is replaced by the trait “Submissiveness,” which is not associated with any of the other 6 PD types in that model. Source: Courtesy of Thomas F. Oltmanns and Robert E. Emery, based on the DSM-5.

personality disorders CHAPTER 9 245

of impairment in self functioning, Patricia demonstrated exces- sive reliance on others for self-definition and regulation of her self-esteem. She desperately wanted others to recognize her supe- riority. She also suffered from clear impairment in interpersonal functioning, including an inability to empathize with the prob- lems of her coworkers. Based on these observations, she would qualify for a diagnosis of personality disorder.

The more specific nature of her personality disorder would then be described in terms of a combination of traits related to antagonism (grandiosity, hostility, and manipulativeness), high negative affectivity (anxiousness, depressivity, and suspicious- ness), detachment (withdrawal and restricted affectivity), and rigid perfectionism. If we used the DSM-5 categorical approach for diagnosis, she would meet the criteria for narcissistic personal- ity disorder. But that approach would also require that the clini- cian note the presence of some features of paranoid PD (such as unjustified doubts about the loyalty of coworkers; reacting with rage to perceived attacks on her character or reputation) and ob- sessive–compulsive PD (excessive devotion to work to the exclu- sion of leisure activities and friendships), even though she did not exhibit enough features of these other disorders to meet their diagnostic threshold. In several ways, the new dimensional ap- proach offers a more straightforward and comprehensive descrip- tion of Patricia’s personality pathology.

Frequency Personality disorders are generally considered to be among the most common forms of psychopathology, when they are consid- ered as a general category. Several epidemiological studies in the United States and in Europe have used structured diagnostic in- terviews to assess personality disorders in samples of people living in the community.

Prevalence in Community and Clinical Samples How many people in the general population would meet the criteria for at least one personality disorder if they were given a diagnostic interview? In studies that have examined community- based samples of adults, the overall lifetime prevalence for hav- ing at least one personality disorder (any type) is approximately 10 percent (Lenzenweger et al., 2007; Trull et al., 2010). While this figure tends to be relatively consistent from one study to the next, prevalence rates for specific types of personality disorders vary quite a bit. The highest prevalence rates are usually found to be associated with obsessive–compulsive personality disorder, antisocial personality disorder, and avoidant personality disorder, which may affect 3 or 4 percent of adults.

The most precise information that is available regarding the prevalence of personality disorders in community samples is concerned specifically with the antisocial type. In two large- scale epidemiological studies of mental disorders, structured interviews were conducted with several thousand participants.

adequately appreciate her skill or the amount of time she put in at work. She reported that she was beginning to think that perhaps she had something to do with their apparent dislike of her. How- ever, even during the initial treatment sessions, her descriptions of her past and current job situations quickly and inevitably reverted to defensive statements concerning others’ mistreatment and lack of appreciation of her. Despite her stated goal of changing her own behavior to be better liked, it quickly became clear that her actual wish was to cause her coworkers and supervisors to realize her su- periority and to treat her accordingly.

Patricia often made condescending remarks about cowork- ers working under her, indicating that they were inferior to her in intelligence and abilities and thus had little or nothing to of- fer her. Patricia pretended to have a back injury as an excuse to avoid sales work, thus forcing the other employees to do this less pleasant job while she was given more prestigious loan accounts. [She] also reported one incident in which a friend had agreed to meet her for dinner but was late because her child was ill. Patricia was highly offended and irritated by what she referred to as her friend’s “lack of consideration” in being late. She felt no compas- sion for her friend or the child.

Patricia’s tendency toward suspiciousness was exemplified by her belief that others did not like her and conspired against her to make her job harder (e.g., by “purposely” failing to get necessary paperwork to her on time). Finally, her uncooperative- ness was illustrated by her tendency not to follow instructions at work and to refuse to cooperate with her husband at home. For example, although her boss had asked Patricia not to stay at the bank after hours because of security considerations, she often stayed late to work, saying that the boss’s request was “stupid and restrictive.”

Patricia described herself as both depressed and anxious. She also tended to become enraged when criticized or “treated badly.” Although Patricia denied feelings of humiliation and in- security, when criticized [she] would blush and either defensively make excuses for her behavior or negate the criticism (“She’s just envious of me because I’m smarter than she is”).

Other people seldom called or visited with her to talk about their problems; when they did, she responded with intellectual advice usually delivered in a condescending manner, such as, “When you’re older, you’ll understand better how things are.” Her solitary nature in having few friends and keeping to herself at work may in fact have resulted in part from actual rebuffs from others in response to her antagonistic behavior.

Finally, Patricia perceived herself as accomplished, persis- tent, and strongly committed to the highest standards of conduct. These impressions may indicate a classic narcissistic inflation of self- image, especially given that she was, even by her own report, hav- ing considerable difficulties at work (Corbitt, 2002, pp. 294–297).

The dimensional approach to diagnosing PDs would begin with a consideration of level of personality functioning. In terms

246 CHAPTER 9 personality disorders

Stability of Personality Disorders over Time Temporal stability is one of the most important assumptions about personality disorders. Evidence for the assumption that personality disorders appear during adolescence and persist into adulthood has, until recently, been limited primarily to antiso- cial personality disorder. One classic follow-up study (Robins, 1966) began with a large set of records describing young children treated for adjustment problems at a clinic during the 1920s. The investigator was able to locate and interview almost all of these people, who by then were adults. The best predictor of an adult diagnosis of antisocial personality was conduct disorder in child- hood. The people who were most likely to be considered antiso- cial as adults were boys who had been referred to the clinic on the basis of serious theft or aggressive behavior; who exhibited such behaviors across a variety of situations; and whose antisocial behaviors created conflict with adults outside their own homes. More than half of the boys who exhibited these characteristics were given a diagnosis of antisocial personality disorder as adults.

Another longitudinal study has collected information regard- ing the prevalence and stability of personality disorders among adolescents (Cohen et al., 2005). This investigation is particularly important because it did not depend solely on subjects who had been referred for psychological treatment and because it was con- cerned with the full range of personality disorders. The rate of personality disorders was relatively high in this sample: Seventeen percent of the adolescents received a diagnosis of at least one per- sonality disorder. Categorically defined diagnoses were not par- ticularly stable; fewer than half of the adolescents who originally qualified for a personality disorder diagnosis met the same criteria two years later. Nevertheless, many of the study participants con- tinued to exhibit similar problems over the next 20 years. Viewed from a dimensional perspective, the maladaptive traits that rep- resent the core features of the disorders remained relatively stable between adolescence and young adulthood (Crawford, Cohen, & Brook, 2001).

The overall lifetime prevalence rate for antisocial personality disorder (men and women combined) was 3 percent in both studies (Kessler et al., 1994; Robins & Regier, 1991). The prev- alence rates for other specific types tend to be approximately 1 or 2 percent of the population. The most obvious exception is narcissistic personality disorder, which appears to be the least common form, affecting much less than 1 percent of the population.

One final issue regarding prevalence rates involves comor- bidity. There is considerable overlap among categories in the per- sonality disorders. At least 50 percent of people who meet the diagnostic criteria for one personality disorder also meet the crite- ria for another disorder (Coid et al., 2006). To some extent, this overlap is due to the fact that similar symptoms are used to define more than one disorder. For example, impulsive and reckless be- haviors are part of the definition of both antisocial and borderline PDs. Social withdrawal is used to define schizoid, schizotypal, and avoidant PD.

There is also extensive overlap between personality disorders and other kinds of mental disorder. Approximately 75 percent of people who qualify for a personality disorder diagnosis also meet criteria for a syndrome such as major depression, substance de- pendence, or an anxiety disorder (Dolan-Sewell, Krueger, & Shea, 2001). This overlap may also be viewed from the other direction: Many people who are treated for another type of mental disor- der, such as depression or alcoholism, would also meet the criteria for a personality disorder (Thomas, Melchert, & Banken, 1999). Borderline personality disorder appears to be the most common personality disorder among patients treated at mental health fa- cilities (both inpatient and outpatient settings). Averaged across studies, the evidence suggests that this disorder is found among slightly more than 30 percent of all patients who are treated for psychological disorders (Lyons, 1995).

Gender Differences The overall prevalence of personality disorders is approximately equal in men and women (Lenzenweger, 2007). There are, how- ever, consistent gender differences with regard to at least one spe- cific disorder: Antisocial personality disorders is unquestionably much more common among men than among women, with rates of approximately 5 percent reported for men and 2 percent for women (Trull et al., 2010). Thus, antisocial personality disorder is actually an alarmingly common problem among adult males in the United States.

Epidemiological evidence regarding gender differences for the other types of personality disorders is much more ambigu- ous. Borderline personality disorder and dependent personality disorder may be somewhat more prevalent among women than men, but the evidence is not strong (Skodol & Bender, 2003). There has been some speculation that paranoid and obsessive– compulsive personality disorders may be somewhat more com- mon among men than women (Coid et al., 2006).

Vivien Leigh won an Academy Award for her performance as Blanche DuBois in A Streetcar Named Desire (1951). She also won for her performance as Scarlett O’Hara in Gone with the Wind (1939). Both characters exhibit blends of histrionic and narcissistic PD features.

personality disorders CHAPTER 9 247

self-centered and egotistical in a collectivist society, such as Japan, might appear to be normal in an individualistic society like the United States.

The personality disorders may be more closely tied to cul- tural expectations than any other kind of mental disorder ( Alarcon, 2005). Some studies have compared the prevalence and symptoms of personality disorders in different countries, and the data suggest that similar problems do exist in cultures outside the United States and Western Europe (Pinto et al., 2000; Yang et al., 2000). Nevertheless, much more information is needed before we can be confident that the DSM-5 system for describing personality disorders is valid in other societies. Two questions are particularly important:

1. In other cultures, what are the personality traits that lead to marked interpersonal difficulties and social or occupational impairment? Are they different from those that have been identified for our own culture?

2. Are the diagnostic criteria that are used to define personality disorder syndromes in DSM-5 (and ICD-10) meaningful in other cultures?

Cross-cultural studies that are designed to address these issues must confront a number of difficult methodological problems (see Research Methods).

Within a particular society, the experiences of people from cultural and ethnic minorities should also be considered care- fully before diagnostic decisions are made. Phenomena asso- ciated with paranoid personality disorder, including strong feelings of suspicion, alienation, and distrust, illustrate this issue. People who belong to minority groups (and those who are recent immigrants from a different culture) are more likely

Several studies have examined the stability of personality dis- orders among people who have received professional treatment for their problems, especially those who have been hospitalized for schizotypal or borderline disorders. Many patients who have been treated for these problems are still significantly impaired several years later, but the disorders are not uniformly stable (Paris, 2003; Skodol et al., 2008). Recovery rates are relatively high among patients with a diagnosis of borderline personality disorder. If patients who were initially treated during their early twenties are followed up when they are in their forties and fifties, only about one person in four would still qualify for a diagno- sis of borderline personality disorder (Zanarini et al., 2006). The long-term prognosis is less optimistic for schizotypal and schizoid personality disorders. People with these diagnoses are likely to remain socially isolated and occupationally impaired.

Culture and Personality In DSM-5, personality disorders are defined in terms of behavior that “deviates markedly from the expectations of the individual’s culture.” In setting this guideline, the authors of DSM-5 recog- nized that judgments regarding appropriate behavior vary con- siderably from one society to the next. Some cultures encourage restrained or subtle displays of emotion, whereas others promote visible, public displays of anger, grief, and other emotional re- sponses. Behavior that seems highly dramatic or extraverted (histrionic) in the former cultures might create a very different impression in the latter cultures. Cultures also differ in the extent to which they value individualism (the pursuit of personal goals) as opposed to collectivism (sharing and self-sacrifice for the good of the group; Triandis, 1994). Someone who seems exceedingly

Is this young Afghan woman more extraverted than the others? Is she a risk-taker? It is impos- sible to make these personality judgments without more knowledge of the culture in which she lives. She may be unveiled because she is younger than the other women, or because she is not married.

248 CHAPTER 9 personality disorders

disorder if they do not recognize or understand the cultural experiences in which they are formed. In this particular case, it is obviously important for the clinician to consider the per- son’s attitudes and beliefs regarding members of his or her own family or peer group, as well as the person’s feelings about the community as a whole.

than members of the majority or dominant culture to hold realistic concerns about potential victimization and exploita- tion. For example, black Americans may develop and express mild paranoid tendencies as a way of adapting to ongoing experiences of oppression (Whaley, 2001). Clinicians may er- roneously diagnose these conditions as paranoid personality

rESEarCh methods

Cross-Cultural Comparisons: The Importance of Context

Over the past 40 years, psychologists have begun to adopt a broader focus in their consideration of human behavior, including mental disorders. This means pay- ing more attention to cultural diversity in the samples used in research studies.

At the broadest level, culture is a system of meanings that de- termines the ways in which people think about themselves and their environments. It shapes their most basic view of reality. Consider, for example, the process of bereavement following the death of a close relative. In some Native American cultures, people learn to expect to hear the spirit of the dead person calling to them from the afterworld (Kleinman, 1988). This is a common experience for people in these cultures. It resembles auditory hallucinations (perceptual experiences in the absence of external stimulation) that are seen in people with psychotic disorders. But among some Native American peoples, hearing voices from the dead is a “normative” or common response; it is not a sign of dysfunction. Perhaps most importantly, this type of experience is not regularly associated with social or occupational impairment. It would be a mistake, therefore, to consider these experiences to be symptoms of a mental disorder.

Cross-cultural psychology is the scientific study of ways that human behavior and mental processes are influenced by social and cultural factors (Berry et al., 2002). This field includes the study of ethnic differences (among cultural groups living in close proximity within a single nation). Comparison is a fundamental element of any cross-cultural study. Cross-cultural psychologists examine ways in which human behaviors are different, as well as ways in which they are similar, from one culture to the next.

Cross-cultural comparisons are relevant to the study of psycho- pathology in many ways (Draguns & Tanaka-Matsumi, 2003; Kirmayer, 2006). One way involves epidemiology—comparisons of the prevalence of disorders across cultures. Investigations aimed at etiological mechanisms, including biological, psycho- logical, and social variables, can also be extremely informative when viewed in cross-cultural perspective. For example, we know that negative patterns of thinking are correlated with depressed mood in middle-class Americans. Is the same rela- tionship found among people living in rural China? Virtually any study of psychopathology would provide useful information if it were replicated in different cultures.

The valuable process of making cross-cultural comparisons can actually be quite difficult (Draguns, 2006; Ratner & Hui, 2003). Several complex issues must be faced by investigators who want to study psychopathology in cross-cultural perspective:

1. Identifying meaningful groups: The first step in making cross- cultural comparisons is the selection of participants who are representative members of different cultures. This might be a relatively straightforward process if the comparison is to be made between two small, homogeneous groups such as two isolated rural villages in two very different countries (say, Peru and Zimbabwe). The situation becomes much more complex if the investigator’s goal is to compare ethnic groups within a large, multicultural society such as the United States. Hispanic Americans, for example, include people whose cultural back- grounds can be traced to many different Spanish-speaking homelands with very different cultural traditions, such as Puerto Rico, Mexico, and Cuba. Even greater cultural diversity is found among various Native American peoples. How do we determine which people share a common culture? What is the “cultural unit,” and how do we find its boundaries?

2. Selecting equivalent measurement procedures: Comparison between groups can be valid only if equivalent measurement procedures are used in both cultures (or in all groups). Par- ticipants in different cultures often speak different languages (or different dialects). Questionnaires and psychological tests must be cross-validated to ensure that they measure the same concepts in different cultures.

3. Considering causal explanations: Suppose that investigators identify a reliable difference between people in two different cultures. They must now decide how to interpret this differ- ence. Is it, in fact, due to cultural variables? Or would the differences disappear if other variables, such as poverty, edu- cation, and age, were held constant between the two groups?

4. Avoiding culturally biased interpretations: Investigators, who are often middle class and white, must interpret the results of cross-cultural research cautiously. In particular, scientists must not interpret differences between cultures or ethnic groups as being indicative of deficits in minority groups or non-Western cultures. Some cross-cultural psychologists have suggested that it is more important to study developmental processes within cultures or ethnic groups than to compare outcomes between groups.

personality disorders CHAPTER 9 249

strained one’s intuitive capacities to the uttermost just to figure out what was really bothering her or what was the “main theme” on any particular day.

Her empathic skills were very limited, leading her to com- ment at times that she found people and their motives com- pletely puzzling: “I can’t connect up with them. If they invite me to lunch with them, I can’t seem to join in the conversation or else I say the wrong thing, so after a while they don’t invite me anymore and I eat by myself.” If a teaching supervisor wore a dour expression walking down the hall, Sandra assumed the supervisor was dissatisfied with her work, even though it might be a person who was not even assigned to her department. She tended to be surly and “superior” sounding when asking for vacation requests and the like—and often didn’t get what she wanted because of having alienated the people whose favor she needed. This reinforced her notion that the world was pretty much against her.

Although considered a knowledgeable teacher, she had no charm or patience with the children and was eventually given a semi-administrative job where little interaction with others was necessary. With boyfriends, she was comfortable about having sex but made such fussy and endless-seeming preparations (such as doing her fingernails in the bathroom for half an hour) that the men lost the mood and usually ended the relationship after a few months.

More striking than her empathic difficulties was a curious inability to grasp what one might call the statistics of everyday life. Travel was a great burden, since she felt it necessary to plan for all possible contingencies. She once went to (France) on an August vacation packing her winter overcoat, because, as she reminded me, “There was a cold spell there in the ’50s and it could happen again.” Furthermore, she sent a packet of clothes on ahead to the hotel because, “What if my baggage got stolen?” She had great difficulty, in other words, aligning her behavior in harmony with the expectable, in contrast with the remotely possible—all think- able events being in her mind equally probable (Stone, 1993, pp. 179–180).

Symptoms The DSM-5 criteria for schizotypal personality disorder are listed in “DSM-5: Schizotypal Personality Disorder.” These criteria represent a blend of those characteristics that have been reported among the relatives of schizophrenic patients and those symp- toms that seem to characterize nonpsychotic patients with schizo- phrenic-like disorders (Esterberg, Goulding, & Walker, 2010). In addition to social detachment, emphasis is placed on eccentric- ity and cognitive or perceptual distortions.

People who meet the criteria for schizotypal personality disorder frequently meet the criteria for additional disorders. There is considerable overlap between schizotypal personal- ity disorder and other personality disorders in Cluster A (para- noid and schizoid), as well as with avoidant personality disorder.

Schizotypal Personality Disorder (SPD) Now that we have reviewed some of the important general issues for the entire set of personality disorders, we consider three specific types of disorders in more detail. We focus on schizotypal, borderline, and antisocial types because they have been the subject of extended research and debate in the scien- tific literature.

We begin each of the three sections with a brief case study. We have chosen cases that are prototypes for each dis- order. In other words, these are people who exhibit most, if not all, of the features of the disorder. You should not infer from these descriptions that everyone who meets the criteria for these disorders would represent this type of typical case. Remember, also, that many people simultaneously meet the criteria for more than one personality disorder; these cases are relatively simple examples. The following case illustrates some of the most important features of schizotypal personality disorder (SPD).

The concept of schizotypal personality disorder is closely tied to the history of schizophrenia as a diagnostic entity (Gottesman, 1987). The term was originally coined as an ab- breviation for schizophrenic phenotype. These maladaptive per- sonality traits are presumably seen among people who possess the genotype that makes them vulnerable to schizophrenia. The symptoms of schizotypal personality disorder represent early manifestations of the predisposition to develop the full- blown disorder. It has been recognized for many years that a fairly large proportion of the family members of schizo- phrenic patients exhibit strange or unusual behaviors that are similar to, but milder in form than, the disturbance shown by the patient.

Schizotypal Personality Disorder Sandra, when she first came for treatment at the age of 27, pre- sented with marked anxiety in social situations and in getting along with coworkers, eccentric behavior, and paranoid ideas. She had no close female friends and only one male friend, and though the latter was a sexual relationship, she revealed almost nothing to him about her past. She had many strange beliefs involving astrology, foods, and medicines.

Sandra had only one friend during her adolescence: some- one who shared her faddishness about foods and her beliefs in astrology. Girls excluded her from their school clubs. She never understood why they rejected her, though it is probable that they considered her “weird” because of her inability to make small talk, and her voice pattern: a flat, high-pitched, stilted-sounding monotone that made her come across as mannered and insincere. Added to this peculiarity of speech was her tendency to skip from topic to topic abruptly, giving equal emphasis to each, such that it was difficult to distinguish the trivial from the important. From a therapeutic standpoint, this was particularly bedeviling, since it

250 CHAPTER 9 personality disorders

Treatment Two important considerations complicate the treatment of peo- ple with personality disorders in general and SPD in particular and make it difficult to evaluate the effectiveness of various forms of intervention. One consideration involves the ego-syntonic na- ture of many personality disorders (discussed earlier). Many peo- ple with these disorders do not seek treatment for their problems because they do not see their own behavior as being the source of distress. A related difficulty involves premature termination: A relatively high proportion of personality disorder patients drop out of treatment before it is completed.

When people with personality disorders appear at hospitals or clinics, it is often because they are also suffering from another type of mental disorder, such as depression or a substance use dis- order. This comorbidity is the second consideration that compli- cates treatment. “Pure forms” of personality disorder are relatively rare. There is tremendous overlap between specific personality disorder categories and other forms of abnormal behavior. Treat- ment is seldom aimed at problem behaviors that are associated with only one type of personality disorder, and the efficacy of treatment is, therefore, difficult to evaluate.

The literature regarding treatment of schizotypal person- ality disorder, like that dealing with its causes, mirrors efforts aimed at schizophrenia. A few studies have focused on the pos- sible treatment value of antipsychotic drugs, which are effec- tive with many schizophrenic patients. Some studies have found that low doses of antipsychotic medication are beneficial in al- leviating cognitive problems and social anxiety in patients who have received a diagnosis of schizotypal personality disorder

This finding is not particularly surprising, given the conceptual or- igins of the schizotypal category. There is also quite a bit of overlap between schizotypal personality disorder and borderline personal- ity disorder.

Causes Most of the interest in the etiology of schizotypal personal- ity disorder has focused on the importance of genetic factors. Is schizotypal personality disorder genetically related to schizo- phrenia? Family and adoption studies indicate that the answer is yes? (Reichborn-Kjennerud, 2010). Twin studies have examined genetic contributions to schizotypal personality disorder from a dimensional perspective in which schizotypal personality traits are measured with questionnaires. This evidence also points to a significant genetic contribution (Linney et al., 2003).

The first-degree relatives of schizophrenic patients are consid- erably more likely than people in the general population to exhibit symptoms of schizotypal personality disorder. Several studies have examined the prevalence of schizotypal personality disorder among the parents and siblings of patients being treated for schizophrenia (Tienari et al., 2003). The most striking and consistent finding has been an increased prevalence of schizotypal personality disor- der among the relatives of the schizophrenic patients. Prevalence rates for paranoid and avoidant personality disorder also tend to be higher among the relatives of the schizophrenic patients. These types of personality disorders are not more prevalent among the relatives of people with major depression. Results from these stud- ies are consistent with the conclusion that schizotypal personality disorder is genetically related to schizophrenia.

criteria for

Schizotypal Personality Disorder

A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual dis- tortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Ideas of reference (excluding delusions of reference). 2. Odd beliefs or magical thinking that influences behavior

and is inconsistent with subcultural norms (such as super- stitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).

3. Unusual perceptual experiences, including bodily illusions.

4. Odd thinking and speech (such as vague, circumstantial, metaphorical, overelaborate, or stereotyped).

5. Suspiciousness or paranoid ideation. 6. Inappropriate or constricted affect.* 7. Behavior or appearance that is odd, eccentric, or peculiar. 8. Lack of close friends or confidants other than first-degree

relatives. 9. Excessive social anxiety that does not diminish with

familiarity and tends to be associated with paranoid fears rather than with negative judgments about self.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic fea- tures, another psychotic disorder, or autism spectrum disorder.

DSM-5

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

*Inappropriate affect refers to emotional responses that appear to be inconsistent with the social context—for example, uncontrollable giggling at a wake or funeral. Constricted affect refers to the absence of emotional responsiveness, such as lack of facial expressions. See Chapter 13 for a more detailed discussion.

personality disorders CHAPTER 9 251

fists, sometimes necessitating help from the police. She would then threaten to kill herself.

Lacking any hobbies or interests, apart from dancing, she was bored to distraction at home, yet afraid to venture out. Noth- ing gave her any pleasure except glitzy clothes (which her agora- phobia rendered irrelevant).

For a few weeks Barbara dated a man from her neighbor- hood, and although she was able to leave the house if she were with him, she used the opportunity in a self-destructive way, go- ing to wild nightclubs and provoking him with demands to the point where he drove her only halfway home, pushing her out of the car, so that she had to hitchhike home at 2 a.m. This pre- cipitated a suicide attempt with a variety of medications (Stone, 1993, pp. 248–249).

The intellectual heritage of BPD is quite diverse and more dif- ficult to trace than that of schizotypal personality disorder. One influential perspective on these problems developed from psycho- dynamic theory (Kernberg, 1967, 1975). According to this view, borderline personality is not a specific syndrome. Rather, it refers to a set of personality features that can be found in individuals with various disorders. The common feature of people with borderline personality is splitting—the tendency to see people and events alter- nately as entirely good or entirely bad. Thus, a man might perceive his wife as almost perfect at some times and as highly flawed at other times. The tendency toward splitting helps explain the broad mood swings and unstable relationships associated with borderline personality. Viewed from this perspective, borderline personality can encompass many types of abnormal behavior, including para- noid and schizoid personality disorders, impulse control disorders (see Impulse Control Disorders), substance use disorders, and vari- ous types of depression. Psychodynamic views regarding personal- ity organization were eventually transformed into a definition of borderline personality disorder (Gunderson, 1984, 1994).

(Koenigsberg et al., 2003). There is also some indication that patients with schizotypal personality disorder may respond pos- itively to antidepressant medications, including SSRIs. In gen- eral, the therapeutic effects of medication are positive, but they tend to be modest.

Clinical experience suggests that these patients do not re- spond well to insight–oriented psychotherapy, in part because they do not see themselves as having psychological problems and also because they are so uncomfortable with close personal rela- tionships. Some clinicians have suggested that a supportive, edu- cational approach that is focused on fostering basic social skills may be beneficial if the goals of treatment are modest (Crits- Christoph, 1998; Gabbard, 2000). Unfortunately, controlled studies of psychological forms of treatment with schizotypal per- sonality disorder have not been reported.

Borderline Personality Disorder (BPD) Borderline personality disorder is one of the most perplexing, most disabling, and most frequently treated forms of personality disorder. Because of the severity of their problems, people with BPD are more likely to come into clinics seeking treatment. The following case illustrates many of the features associated with borderline personality disorder.

Borderline Personality Disorder Barbara, single woman of 24, sought treatment with me shortly after discharge from a hospital, where she had spent three weeks because of depression, panic attacks, and a suicide gesture. This had been her seventh hospitalization—all of them brief, and all for similar symptoms—since age 17. Cheerful and cooperative as a young girl, she underwent a radical change of personality at the time of her menarche. Thereafter, she became irascible, rebel- lious, moody, and demanding.

For a time she was anorexic; later on, bulimic (maintaining her normal weight by vomiting). Schoolwork deteriorated, and she took up with a wild crowd, abusing marijuana and other drugs and engaging in promiscuous sex. At one point she ran away from home with a boyfriend and didn’t return for three months.

She quit high school with one year to go. Her life became even more chaotic; she scratched her wrists on a number of occa- sions, and consorted with abusive men who would use her sexu- ally and then beat her up.

By the time I began working with Barbara, she had been abusing alcohol for about a year and had also become addicted to benzodiazepines. Her proneness to panic-level anxiety now took the form of agoraphobia, necessitating her being accompa- nied by a parent to her therapy sessions. Premenstrually, her ir- ritability rose to fever pitch: she would strike her parents with her

Some people with borderline personality disorder engage in recurrent suicidal gestures of self-mutilating behavior.

252 CHAPTER 9 personality disorders

Borderline personality disorder overlaps with several other PD categories, including the histrionic, narcissistic, paranoid, de- pendent, and avoidant types. There is also a significant amount of overlap between borderline personality disorder and major depression (Trull, Stepp, & Solhan, 2006). Many patients with other types of impulse control problems, such as substance de- pendence and eating disorders, also qualify for a diagnosis of borderline personality disorder.

Follow-up studies suggest many similarities between borderline personality disorder and depressive disorders. In many cases, the symptoms of BPD are evident before the onset of major depression. For example, one study focused on a group of 100 outpatients with a diagnosis of borderline person- ality disorder (Akiskal, 1992). During follow-up, 29 percent of

Symptoms The DSM-5 criteria for borderline personality disorder are pre- sented in “DSM-5: Borderline Personality Disorder”. The over- riding characteristic of borderline personality disorder is a pervasive pattern of instability in self-image, in interpersonal rela- tionships, and in mood.

To be borderline means to lack grounding emotionally and to exist from moment to moment without any sense of con- tinuity, predictability, or meaning. Life is experienced in frag- ments, more like a series of snapshots than a moving picture. It is a series of discrete points of experience that fail to flow together smoothly or to create an integrated whole.

(Moskovitz, 1996, pp. 5–6)

Impulse Control Disorders

Failure to control harmful impulses is associated with several of the disorders listed in DSM-5. People who meet the criteria for borderline personality disorder and antisocial personality disorder engage in various types of impulsive, mal- adaptive behaviors (most often self-mutilation in the case of BPD, and theft and aggression in the case of ASPD). People in the midst of a manic episode frequently become excessively involved in pleasurable activities that can have painful consequences, such as unrestrained buying or sexual indiscretions. These are ex- amples of impulse control problems that appear as part of a more broadly defined syndrome or mental disorder.

DSM-5 includes several additional problems under a heading called impulse control disorders (Hollander & Stein, 2006). Relatively little is known about these problems. They are defined in terms of per- sistent, clinically significant impulsive behaviors that are not better explained by other disorders in DSM-5. They include the following:

• Intermittent explosive disorder: Aggressive behaviors resulting in serious assaultive acts or destruction of property (Coccaro, Posternak, & Zimmerman, 2005; Olvera, 2002). The level of aggression is grossly out of proportion to any precipitating psychosocial stressors.

• Kleptomania: Stealing objects that are not needed for per- sonal use or for their financial value. The theft is not moti- vated by anger or vengeance (Presta et al., 2002).

• Pyromania: Deliberate and purposeful setting of fires, accom- panied by fascination with or attraction to fire and things that are associated with it. The behavior is not motivated by finan- cial considerations (as in arson), social or political ideology, anger, vengeance, or delusional beliefs (Lejoyeux, McLoughlin, & Ades, 2006).

This broad diagnostic group also used to include pathological gambling, but that problem has been moved to the DSM-5 section on Substance Use Disorders (see Chapter 11).

In most cases, the impulsive behavior is preceded by increasing tension and followed by a feeling of pleasure, gratification, or relief. The motivation for these impulsive behaviors is, therefore, somewhat different than the motivation for compulsive behavior (see Chapter 6). Impulsive and compulsive behaviors can be dif- ficult to distinguish, as both are repetitious and difficult to resist. The primary difference is that the original goal for impulsive be- havior is to experience pleasure, and the original goal for com- pulsive behavior is to avoid anxiety (Frances, et al., 1995; Grant & Potenza, 2006).

The impulse control disorders occupy an interesting and con- troversial niche in DSM-5. The implication of impulse control disorders is that people who repeatedly engage in dangerous, illegal, or destructive behaviors must have a mental disorder. If they do not, why do they do these things? Unfortunately, this reasoning quickly becomes circular. Why does he set fires recklessly? Because he has a mental disorder. How do you know he has a mental disorder? Because he sets fires reck- lessly. This logical dilemma is particularly evident in the case of impulse control disorders when the problem behaviors do not appear as part of a broader syndrome in which other symptoms of disorder are also present. In other words, the problem behavior is the disorder. Until we can step outside this loop, validating the utility of the diagnostic concept by reference to other psychological or biological response sys- tems, we are left with an unsatisfying approach to the defini- tion of these problems.

personality disorders CHAPTER 9 253

relationships with their parents. Adolescent girls with borderline personality disorder report pervasive lack of supervision, frequent witnessing of domestic violence, and being subjected to inap- propriate behavior by their parents and other adults, including verbal, physical, and sexual abuse (Helgeland & Torgersen, 2004; Pally, 2002). The extent and severity of abuse vary widely across individuals. Many patients describe multiple forms of abuse by more than one person.

The association between borderline personality disorder and the patients’ recollections of childhood maltreatment raises an important question about the direction of this relationship: Does childhood abuse lead to borderline personality disorder? Or are people with borderline personality disorder simply more likely to remember that they were abused by their parents, due to biased reporting?

Longitudinal data from a study of adolescents in upstate New York provide important evidence on this point (Johnson et al., 1999). Rather than relying exclusively on self-report measures, the investigators obtained data on child maltreatment from the New York State Central Registry for Child Abuse. Maltreatment included documented cases of physical abuse, sexual abuse, and childhood neglect. People with documented evidence of child- hood abuse and neglect were four times more likely than those who had not been mistreated to develop symptoms of personal- ity disorders as young adults. Strongest connections were found for Cluster B disorders (see Figure 9.1). Physical abuse was most closely associated with subsequent antisocial personality disorder; sexual abuse with borderline personality disorder; and childhood neglect with antisocial, borderline, narcissistic, and avoidant

the sample developed severe depression. Another longitudinal study of patients who were discharged from a private psychi- atric hospital is also interesting in this regard. In a sample of patients with a pure diagnosis of borderline personality disor- der (that is, those who were not diagnosed with any additional mental disorders), 23 percent developed major depressive epi- sodes during the course of the 15-year follow-up (McGlashan, 1986).

Causes Genetic factors are clearly involved in the etiology of borderline personality disorder when it is viewed in terms of the syndrome that is defined in DSM-5 (Distel et al., 2010). Furthermore, the fundamental personality traits that serve to define the disorder, such as neuroticism and impulsivity, are also influenced by ge- netic factors (Livesley, 2008). The most important question is how a genetic predisposition toward certain personality charac- teristics can interact with various types of detrimental environ- mental events to produce the problems in emotional regulation and attachment relationships that are seen among patients with borderline personality disorder.

Some investigators have argued that borderline patients suf- fer from the negative consequences of parental loss, neglect, and mistreatment during childhood (Fonagy & Bateman, 2008). This model is supported by studies of the families of borderline pa- tients and by comparisons with the literature on social develop- ment in monkeys that examined the effects of separating infants from their mothers. Studies of patients with borderline personality disorder do point toward the influence of widespread problematic

DSM-5 criteria for

Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relation- ships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)

2. A pattern of unstable and intense interpersonal relation- ships characterized by alternating between extremes of idealization and devaluation.

3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

4. Impulsivity in at least two areas that are potentially self- damaging (e.g., spending, sex, substance abuse, reckless

driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)

5. Recurrent suicidal behavior, gestures, or threats, or self- mutilating behavior.

6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling

anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

254 CHAPTER 9 personality disorders

developed and evaluated by Marsha Linehan (Linehan, Cochran, & Kehrer, 2001), a clinical psychologist at the University of Washington. This procedure combines the use of broadly based behavioral strategies with the more general principles of support- ive psychotherapy. In philosophy, the term dialectics refers to a process of reasoning that places opposite or contradictory ideas side by side. In Linehan’s approach to treatment, the term re- fers to strategies that are employed by the therapist in order to help the person appreciate and balance apparently contradictory needs to accept things as they are (such as intense negative emo- tions) and to work toward changing patterns of thinking and behavior that contribute to problems in the regulation of emo- tions. Emphasis is placed on learning to be more comfortable with strong emotions, such as anger, sadness, and fear, and learn- ing to think in a more integrated way that accepts both good and bad features of the self and other people. Traditional behavioral and cognitive techniques, such as skill training, exposure, and problem solving, are also employed to help the patient improve interpersonal relationships, tolerate distress, and regulate emo- tional responses. Finally, considerable emphasis is placed on the therapist’s acceptance of patients, including their frequently de- manding, manipulative, and contradictory behaviors. This factor is important, because borderline patients are extremely sensitive to even the most subtle signs of criticism or rejection by other people.

One controlled study of dialectical behavior therapy pro- duced encouraging results with regard to some aspects of the pa- tients’ behavior (Linehan et al., 1994, 1999). All of the patients in this study were women who met diagnostic criteria for BPD and also had a previous history of suicide attempts or deliberate self-harm. Patients were randomly assigned to receive either DBT or treatment as usual, which was essentially any form of treat- ment that was available within the community. The adjustment of patients in both groups was measured after one year of treat- ment and over a one-year period following termination. One of the most important results involved the dropout rate. Almost 60 percent of the patients in the treatment as usual group terminated prematurely, whereas the rate in the DBT group was only 17 per- cent. The patients who received DBT also showed a significant reduction in the frequency and severity of suicide attempts, spent fewer days in psychiatric hospitals over the course of the study, and rated themselves higher on a measure of social adjustment. The groups did not differ, however, on other important measures, such as level of depression and hopelessness.

Positive results have also been reported in more recent stud- ies in which women with BPD were randomly assigned to either dialectical behavior therapy or treatment as usual. Outcome mea- sures indicated that women who were treated with dialectical be- havior therapy experienced more improvement than women in the control groups with regard to symptoms such as depression and hopelessness (Bohus et al., 2004; Koons et al., 2001; Verheul et al., 2003).

personality disorder. These data support the argument that mal- adaptive patterns of parenting and family relationships increase the probability that a person will develop certain types of person- ality disorder.

Treatment Given that the concept of borderline personality disorder is rooted in psychodynamic theory, it should not be surprising that many clinicians have advocated the use of psychotherapy for the treatment of these conditions. In psychodynamic therapy, the transference relationship, defined as the way in which the patient behaves toward the therapist and that is believed to reflect early primary relationships, is used to increase patients’ ability to expe- rience themselves and other people in a more realistic and inte- grated way (Clarkin et al., 2001; Gabbard, 2000).

As we have said, personality disorders have traditionally been considered to be hard to treat from a psychological perspective, and borderline conditions are among the most difficult. Close personal relationships form the foundation of psychological in- tervention, and it is specifically in the area of establishing and maintaining such relationships that borderline patients experi- ence their greatest difficulty (see Getting Help). Their persistent alternation between idealization and devaluation leads to fre- quent rage toward the therapist and can become a significant de- terrent to progress in therapy. Not surprisingly, between one-half and two-thirds of all patients with borderline personality disorder discontinue treatment, against their therapists’ advice, within the first several weeks of treatment (Kelly et al., 1992).

One effective approach to psychotherapy with borderline patients, called dialectical behavior therapy (DBT), has been

figure 9.1 Family Environment and Risk for Personality Disorders Associations between childhood maltreatment and risk for early adulthood person- ality disorders. Source: Based on Cohen et al. Childhood Maltreatment Increases Risk for Personality Disorders during Early Adulthood. Archives of General Psychiatry 1999; 56.

childhood maltreatment absent

childhood maltreatment present

Prevalence of PD, %

Cluster A

Cluster B

Cluster C

P D

C lu

st er

s

0 5 10 15 20 25

personality disorders CHAPTER 9 255

The contrast between Terry’s willingness to blame his prob- lems on his parents and his apparent inability to accept respon- sibility for his own children is striking. It illustrates clearly the callous indifference and shallow emotional experience of the per- son with antisocial personality disorder.

Current views of antisocial personality disorder have been greatly influenced by two specific books. These books have in- spired two different approaches to the definition of the disorder itself. The first book, The Mask of Sanity, was written by Hervey Cleckley (1976), a psychiatrist at the University of Georgia, and was originally published in 1941. It includes numerous case examples of impulsive, self-centered, pleasure-seeking people who seemed to be completely lacking in certain primary emo- tions, such as anxiety, shame, and guilt. Cleckley used the term psychopathy to describe this disorder. According to Cleckley’s definition, the psychopath is a person who is intelligent and superficially charming but is also chronically deceitful, unreli- able, and incapable of learning from experience. This diagnostic approach places principal emphasis on emotional deficits and personality traits. Unfortunately, Cleckley’s definition was difficult to use reliably because it contained such elusive features as “ incapacity for love” and “failure to learn from experience.”

The second book that influenced the concept of antisocial personality disorder was a report by Lee Robins of her follow- up study of children who had been treated many years earlier at a child guidance clinic. The book, Deviant Children Grown Up (1966), demonstrated that certain forms of conduct disorder that

Psychotropic medication is also used frequently in the treat- ment of borderline patients. Unfortunately, no disorder-specific drug has been found. Psychiatrists employ the entire spectrum of psychoactive medication with borderline patients, from anti- psychotics and antidepressants to lithium and anticonvulsants ( Koenigsberg, Woo-Ming, & Siever, 2002; Zanarini & Frankenburg, 2001). Different types of drugs are recommended to treat individual symptoms, such as impulsive aggression, emo- tional instability, and transient paranoid thinking, but there is no systematic proof that a specific drug is effective for any of the borderline features.

Antisocial Personality Disorder (ASPD) Antisocial personality disorder (ASPD) has been studied more thoroughly and for a longer period of time than any of the other personality disorders (Blashfield, 2000). One case study involving this disorder was presented at the beginning of this chapter. Tom, the man in that case, illustrated the pattern of repeated antisocial behavior that is associated with the disorder. Emotional and in- terpersonal problems also play an important role in the definition of antisocial personality disorder. The following case illustrates the egocentricity that is a central feature of the disorder. It also demonstrates the stunning lack of concern that such people have for the impact of their behavior on other people, especially those who are close to them.

Antisocial Personality Disorder Terry is 21, the second of three boys born into a wealthy and highly respected family. His older brother is a doctor, and his younger brother is a scholarship student in his second year of col- lege. Terry is a first-time offender, serving two years for a series of robberies committed a year ago.

By all accounts, his family life was stable, his parents were warm and loving, and his opportunities for success were enor- mous. His brothers were honest and hardworking, whereas he simply “floated through life, taking whatever was offered.” His parents’ hopes and expectations were less important to him than having a good time. Still, they supported him emotionally and financially through an adolescence marked by wildness, testing the limits, and repeated brushes with the law— speeding, reckless driving, drunkenness—but no formal convictions. By age 20 he had fathered two children and was heavily involved in gambling and drugs. When he could no longer obtain money from his fam- ily, he turned to robbing banks, and he was soon caught and sent to prison. “I wouldn’t be here if my parents had come across when I needed them,” he said. “What kind of parents would let their son rot in a place like this?” Asked about his children, he re- plied, “I’ve never seen them. I think they were given up for adop- tion. How the hell should I know!” (Hare, 1993, p. 167).

Bernard Madoff, former U.S. stockbroker and investment counselor, is now serving a 150-year prison sentence for running a massive Ponzi scheme that cheated thousands of people out of their life savings. Grandiosity, deceit, manipulativeness, and lack of remorse are traits associated with the “white-collar psychopath.”

256 CHAPTER 9 personality disorders

feature in this definition is the required presence of symptoms of conduct disorder (see Chapter 16) prior to the age of 15. The definition also requires the presence of at least three out of seven signs of irresponsible and antisocial behavior after the age of 15. One of these criteria, lack of remorse, was one of Cleckley’s origi- nal criteria.

Some investigators and clinicians prefer the concept of psy- chopathy to the DSM-5 definition of antisocial personality. Rob- ert Hare has developed a systematic approach to the assessment of psychopathy, known as the Psychopathy Checklist (PCL), that is based largely on Cleckley’s original description of the disor- der. The PCL includes two major factors (groups of symptoms): (1) emotional/interpersonal traits and (2) social deviance associ- ated with an unstable or antisocial lifestyle. Key symptoms for both factors are summarized in Table 9.4. The major difference between this definition of psychopathy and the DSM-5 definition of antisocial personality disorder involves the list of emotional and interpersonal traits (although DSM-5 does include being deceitful and failure to experience remorse). Extensive research with the PCL indicates that, contrary to previous experience with Cleckley’s criteria, the emotional and interpersonal traits can be used reliably (Hart & Hare, 1997).

The ultimate resolution of this prolonged dispute over the best definition of antisocial personality disorder will depend on systematic comparisons of the two approaches (Lilienfeld, 1994; Widiger, 2006). This situation is another classic example of studying the validity of a diagnostic concept (see Chapter 4). How different are these definitions? Which definition is most useful in predicting events such as repeated antisocial behavior following release from prison?

were evident during childhood, especially among boys, were reli- able predictors of other forms of antisocial behavior when these same people became adults. The diagnostic approach inspired by this research study was adopted for use in DSM-III, and it is still the model included in DSM-5 (APA, 2013). It places principal emphasis on observable behaviors and repeated conflict with, in- cluding failure to conform to, social norms with respect to law- ful behavior. This approach can be used with greater reliability than psychopathy because it is focused on concrete consequences of the disorder, which are often documented by legal records, rather than subjectively defined emotional deficits, such as lack of empathy.

Psychopathy and ASPD are two different attempts to define the same disorder. Yet they are sufficiently different that they cer- tainly do not identify the same people, and they are no longer used interchangeably (Lynam & Vachon, 2012). Critics argue that DSM blurs the distinction between antisocial personality and criminality. Cleckley’s approach had been relatively clear on this point; all criminals are not psychopaths, and all psychopaths are not criminals. The DSM definition makes it difficult to diag- nose antisocial personality disorder in a person who does not al- ready have a criminal record, such as an egocentric, manipulative, and callous businessperson. It also includes a much larger propor- tion of criminals within the boundaries of antisocial personality disorder (Hart & Hare, 1997). The true meaning of the concept may be sacrificed in DSM-5 for the sake of improved reliability.

Symptoms The diagnostic criteria for antisocial personality disorder are listed in “DSM-5: Antisocial Personality Disorder.” One prominent

DSM-5 criteria for

Antisocial Personality Disorder

A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indi- cated by three (or more) of the following: 1. Failure to conform to social norms with respect to lawful

behaviors, as indicated by repeatedly performing acts that are grounds for arrest.

2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.

3. Impulsivity or failure to plan ahead. 4. Irritability and aggressiveness, as indicated by repeated

physical fights or assaults. 5. Reckless disregard for safety of self or others.

6. Consistent irresponsibility, as indicated by repeated fail- ure to sustain consistent work behavior or honor financial obligations.

7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

B. The individual is at least age 18 years.

C. There is evidence of conduct disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

personality disorders CHAPTER 9 257

suggests that, as psychopaths grow older, they may find new out- lets for their aggression, impulsive behavior, and callous disregard for others. For example, they might resort to fraud or child abuse, for which they are less likely to get caught.

Causes Psychologists have studied etiological factors associated with psy- chopathy and antisocial personality disorder more extensively than for any of the other personality disorders. Research studies on this topic fall into three general areas. One is concerned with the biological underpinnings of the disorder, especially the pos- sible influence of genetic factors. The second focus of investiga- tion is social factors. The relationship between familial conflict and the development of antisocial behavior in children falls un- der this general heading. The third group of studies has addressed the nature of the psychological factors that might explain the ap- parent inability of people with antisocial personality disorder to learn from experience.

BIOLOGICAL FACTORS Several investigators have used twin and adoption methods to study the contributions of genetic and environmental factors to the development of antisocial personal- ity disorder and of criminal behavior more generally. The adop- tion strategy is based on the study of adoptees: people who were separated from their biological parents at an early age and raised by adoptive families (see Chapter 2). Several adoption studies have found that the development of antisocial behavior is deter- mined by an interaction between genetic factors and adverse en- vironmental circumstances (Waldman & Rhee, 2006). In other words, both types of influence are important. The highest rates of conduct disorder and antisocial behavior are found among the offspring of antisocial biological parents who are raised in an adverse adoptive environment.

Consider, for example, results from one particularly infor- mative study (Cadoret et al., 1995; Yates, Cadoret, & Trough- ton, 1999). The investigators studied men and women who had been separated at birth from biological parents with anti- social personality disorder. This target group was compared

ANTISOCIAL BEHAVIOR OVER THE LIFE SPAN Not everyone who engages in antisocial behavior does so consistently through- out his or her lifetime. Terrie Moffitt, a clinical psychologist at Duke University, has proposed that there are two primary forms of antisocial behavior: transient and nontransient. Moffitt (1993, 2007) considers adolescence-limited antisocial behavior to be a common form of social behavior that is often adaptive and that disappears by the time the person reaches adulthood. This type presumably accounts for most antisocial behavior, and it is unre- lated to antisocial personality disorder.

A small proportion of antisocial individuals, mostly males, engage in antisocial behavior at all ages. Moffitt calls this type life-course-persistent antisocial behavior. The specific form of these problems may vary from one age level to the next:

Biting and hitting at age 4, shoplifting and truancy at age 10, selling drugs and stealing cars at age 16, robbery and rape at age 22, and fraud and child abuse at age 30. The underly- ing disposition remains the same, but its expression changes form as new social opportunities arise at different points in development.

(Moffitt, 1993, p. 679)

Follow-up studies suggest that in some ways psychopaths tend to “burn out” when they reach 40 or 45 years of age. These changes are most evident for the impulsive, socially deviant kinds of behavior that are represented in the second factor on Hare’s Psychopathy Checklist (Harpur & Hare, 1994). Indeed, older psychopaths are less likely to exhibit a pathological “need for excitement” or to engage in impulsive, criminal behaviors. In contrast to this pattern, personality traits associated with the emotional–interpersonal factor on the PCL, such as deceitfulness, callousness, and lack of empathy, do not become less conspicu- ous over time. These are apparently more stable features of the disorder.

It is not clear whether the age-related decline in social de- viance represents a change in personality structure (improved impulse control and diminished risk taking). Moffitt’s theory

table 9.4 Key Symptoms of Psychopathy Emotional/Interpersonal Traits Social Deviance (Antisocial Lifestyle)

Glib and superficial Impulsive

Egocentric and grandiose Poor behavior controls

Lack of remorse or guilt Need for excitement

Lack of empathy Lack of responsibility

Deceitful and manipulative Early behavior problems

Shallow emotions Adult antisocial behavior

Source: Based on Hare, R. D. 1998. Without Conscience: The Disturbing World of the Psychopaths Among Us. New York: Guilford Press.

258 CHAPTER 9 personality disorders

After a pattern of antisocial behavior has been established during childhood, many factors lock the person into further anti- social activities. Moffitt’s theory emphasizes two sources of conti- nuity. The first is a limited range of behavioral skills. The person does not learn social skills that would allow him or her to pursue more appropriate responses than behaviors such as lying, cheat- ing, and stealing. Once the opportunity to develop these skills is lost during childhood, they may never be learned. The second source of continuity involves the results of antisocial behavior during childhood and adolescence. The person becomes progres- sively ensnared by the aftermath of earlier choices. Many possible consequences of antisocial behavior, including being addicted to drugs, becoming a teenaged parent, dropping out of school, and having a criminal record, can narrow the person’s options.

PSYCHOLOGICAL FACTORS Adoption, twin, and family stud- ies provide clues to the causes of antisocial personality disorder. Another series of studies, beginning in the 1950s and extending to the present, has been concerned with the psychological mecha- nisms that may mediate this type of behavior. These investiga- tions have attempted to explain several characteristic features of psychopathy—such as lack of anxiety, impulsivity, and failure to learn from experience—using various types of laboratory tasks (Fowles & Dindo, 2006).

Subjects in the laboratory tasks are typically asked to learn a sequence of responses in order either to receive a reward or avoid an aversive consequence, such as electric shock or loss of money. Although the overall accuracy of psychopaths’ performance on these tasks is generally equivalent to that of non-psychopathic subjects, their behavior sometimes appears to be unaffected by the anticipation of punishment.

Two primary hypotheses have been advanced to explain the poor performance of psychopaths on these tasks. One point of view is based on Cleckley’s argument that psychopaths are emo- tionally impoverished. Their lack of anxiety and fear is particularly striking. Research support for this hypothesis is based in large part

to a control group of people who had been separated at birth from biological parents with no history of psychopathology. The offspring and their adoptive parents were interviewed to assess symptoms of conduct disorder, aggression, and antisocial behav- ior in the offspring. The adversity of the adoptive home environ- ment was measured in terms of the total number of problems that were present, including severe marital difficulties, drug abuse, or criminal activity. People who were raised in more dif- ficult adoptive homes were more likely to engage in various types of aggressive and antisocial behavior as children and as adults. Furthermore, the harmful effects of an unfavorable environment were more pronounced in the target group than in the control group. In other words, offspring of antisocial parents were much more likely to exhibit symptoms of conduct disorder (truancy, school expulsion, lying, and stealing) as children and exagger- ated aggressive behavior as adolescents if they were raised in an adverse adoptive home environment. Being raised in an adverse home environment did not significantly increase the prob- ability of conduct disorder, aggression, or antisocial behavior among offspring in the control group. Thus, antisocial behavior appeared to result from the interaction of genetic and environ- mental factors.

SOCIAL FACTORS Adoption studies indicate that genetic fac- tors interact with environmental events to produce patterns of antisocial and criminal behavior. The combination of a genetic predisposition toward antisocial behavior and environmental adversity is particularly harmful. What kinds of events might be involved in this process? Obvious candidates include physical abuse and childhood neglect, as indicated by the longitudinal study of adolescents and their families (Farrington, 2006;  Johnson et al., 1999).

How can the interaction between genetic factors and fam- ily processes be explained? Moffitt’s explanation for the etiology of life-course-persistent antisocial behavior depends on the influ- ence of multiple, interacting systems. One pathway involves the concept of children’s temperament and the effect that their char- acteristic response styles may have on parental behavior. Children with a “difficult” temperament—that is, those whose response style is characterized by high levels of negative emotion or ex- cessive activity—may be especially irritating to their parents and caretakers (Bates, Wachs, & Emde, 1994). They may be clumsy, overactive, inattentive, irritable, or impulsive. Their resistance to disciplinary efforts may discourage adults from maintaining per- sistent strategies in this regard. This type of child may be most likely to evoke maladaptive reactions from parents who are poorly equipped to deal with the challenges presented by this kind of behavior. Parents may be driven either to use unusually harsh punishments or to abandon any attempt at discipline. This inter- action between the child and the social environment fosters the development of poorly controlled behavior. Antisocial behavior is perpetuated when the person selects friends who share similar antisocial interests and problems.

Antisocial behavior can be perpetuated when the person selects friends who share similar antisocial interests and problems.

personality disorders CHAPTER 9 259

features are not low anxiety and failure to learn from experience, but lack of shame and pathological egocentricity. According to this perspective, the psychopath is simply a person who has cho- sen, for whatever reason, to behave in a persistently selfish man- ner that ignores the feelings and rights of other people. “Rather than moral judgment being driven by anxiety, anxiety is driven by moral judgment” (Levenson, 1992).

Treatment People with antisocial personalities seldom seek professional mental health services unless they are forced into treatment by the legal system. When they do seek treatment, the general con- sensus among clinicians is that it is seldom effective. This widely held impression is based, in part, on the traits that are used to de- fine the disorder; like people with borderline personality disorder, people with antisocial personality disorder are typically unable to establish intimate, trusting relationships, which obviously form the basis for any treatment program.

The research literature regarding the treatment of antisocial personality disorder is sparse (Harris & Rice, 2006). Very few studies have identified cases using official diagnostic criteria for an- tisocial personality disorder. Most of the programs that have been evaluated have focused on juvenile delinquents, adults who have been imprisoned, or people otherwise referred by the criminal jus- tice system. Outcome is often measured in terms of the frequency of repeated criminal offenses rather than in terms of changes in behaviors more directly linked to the personality traits that define the core of antisocial personality. The high rate of alcoholism and other forms of substance dependence in this population is another problem that complicates planning and evaluating treatment pro- grams aimed specifically at the personality disorder itself.

Although no form of intervention has proved to be effective for antisocial personality disorder, psychological interventions that are directed toward specific features of the disorder might be useful (Wallace & Newman, 2004). Examples are behavioral procedures that were originally designed for anger management and deviant sexual behaviors. Behavioral treatments can appar- ently produce temporary changes in behavior while the person is closely supervised, but they may not generalize to other settings.

on an examination of physiological responses while subjects are performing laboratory tasks. One particularly compelling line of investigation involves the examination of the eye blink startle re- flex. People blink their eyes involuntarily when they are startled by a loud, unexpected burst of noise. For most people, the magnitude of this response is increased if, at the time they are startled, they are engaged in an ongoing task that elicits fear or some other negative emotional state (such as viewing frightening or disgusting stimuli). The magnitude of the startle response is decreased if the person is engaged in a task that elicits positive emotion. Psychopaths’ startle responses follow a pattern different from those observed in normal subjects (Herpertz et al., 2001; Patrick & Zempolich, 1998); they do not show the exaggerated startle response that is indicative of fear in the presence of aversive stimuli. This emotional deficit may explain why psychopaths are relatively insensitive to, or able to ig- nore, the effects of punishment.

The other hypothesis holds that psychopaths have difficulty shifting or reallocating their attention to consider the possible negative consequences of their behavior. Evidence for this expla- nation is based in large part on the observation that psychopaths respond normally to punishment in some situations, but not in others. This is especially evident in mixed-incentive situations, in which the person’s behavior might be either rewarded or pun- ished. Psychopaths are preoccupied with the potential for a suc- cessful outcome. They will continue gambling when the stakes are high, even when the odds are badly against them. And they will pursue a potential sexual encounter, even when the other per- son is trying to discourage their interest. They fail to inhibit inap- propriate behavior because they are less able than other people to stop and consider the meaning of important signals that their behavior might lead to punishment (Hiatt & Newman, 2006; Patterson & Newman, 1993).

Critics of this line of research have noted some problems with existing psychological explanations for the psychopath’s behavior. One limitation is the implicit assumption that most people con- form to social regulations and ethical principles because of anxi- ety or fear of punishment. The heart of this criticism seems to lie in a disagreement regarding the relative importance of Cleckley’s criteria for psychopathy. It might be argued that the most crucial

getting hElP

As we mention in this chapter, many people who would meet the diagnostic criteria for a personality disorder do not enter treatment, at least not voluntarily. Although their interpersonal problems are pervasive and deeply ingrained, they are reluctant or completely unable to see the active role that they play in maintaining their own misfortunes (regard- less of their origins). The pejorative way in which personality

disorders are sometimes portrayed may make some people reluctant to acknowledge that they have a personality disorder. We prefer to discuss these problems in terms of personality limi- tations or maladaptive response styles. No one is perfect. Being able to recognize your own weaknesses is a sign that you are open-minded and willing to change. This is the first important step toward improvement.

Continued

260 CHAPTER 9 personality disorders

Personality disorders are defined in terms of rigid, inflexible, maladaptive ways of perceiving and responding to oneself and one’s environment that lead to social or occupational problems or subjective distress. This pattern must be pervasive across a broad range of situations, and it must be stable and of long duration.

Personality disorders are controversial for a number of reasons, including their low diagnostic reliability and the tremendous overlap among specific personality disorder categories.

Many systems have been proposed to describe the fundamental dimensions of human personality. One popular alternative is the five-factor model, which includes the basic traits of neuroticism, extraversion, openness to experience, agreeableness, and con- scientiousness. Extreme variations in any of these traits—being either pathologically high or low—can be associated with per- sonality disorders.

DSM-5 lists 10 types of personality disorder, arranged in three clusters. There is considerable overlap among and between these

types. Cluster A includes paranoid, schizoid, and schizotypal personality disorders. These categories generally refer to peo- ple who are seen as being odd or eccentric. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. People who fit into this cluster are generally seen as being dramatic, unpredictable, and overly emotional. Cluster C includes avoidant, dependent, and obsessive–compulsive per- sonality disorders. The common element in these disorders is presumably anxiety or fearfulness.

DSM-5 also includes a dimensional approach to the description of personality disorders. This proposal was developed by the workgroup for DSM-5. After considerable debate, it was rejected in favor of retaining the traditional categorical approach. The dimensional approach includes two steps: an assessment of level of personality functioning followed by ratings on 25 maladaptive personality traits. This system offers the advantage of being bet- ter able to account for similarities and differences among people with various combinations of personality traits. It is included in Section III of DSM-5, along with other conditions that require further study.

The overall prevalence of personality disorders among adults in the general population (i.e., the percentage who qualify for the diagnosis of at least one type) is approximately 10 percent. The highest prevalence rates for specific types of personality disor- ders are usually found for obsessive–compulsive, antisocial, and avoidant personality disorders, which may affect 3 or 4 percent of adults. Prevalence rates for other specific types tend to be approximately 1 or 2 percent of the population (or less).

Summary9

It also helps to have a little compassion for yourself, along with the determination to work toward a lasting change in the way you relate to the people and events of your life. Lost in the Mir- ror: An Inside Look at Borderline Personality Disorder by Richard Moskovitz, provides an insightful and sympathetic guide to the painful emotional experiences associated with borderline per- sonality disorder. It also illustrates ways in which these symptoms affect the lives of patients, their families, and their friends.

If you are interested in help because you have to deal with someone who you think may have a personality disorder, you probably feel confused, frustrated, and angry. You may also feel extremely guilty if you blame yourself for problems in the relationship or for the other person’s unhappiness. This may be especially true if you are involved in a romantic relationship or must work closely with someone who might meet the criteria for a PD. Fortunately, it is often possible to adapt to such inter- actions. Several self-help guides provide advice about getting along with difficult people. One good example is Fatal Flaws: Navigating Destructive Relationships with People with Disorders of Personality and Character (Yudofsky, 2005). Most recommend that you begin by learning about the predictable nature of the

other person’s style. Recognize the presence of personality weaknesses and learn how to adapt to them. You must also ac- cept the limits of your own ability to control the other person or to get him or her to change.

Sometimes the only solution is to end the relationship. At their most extreme, people with personality disorders cannot form re- ciprocal, mutually satisfying relationships with other people. This is particularly true in the case of antisocial personality disorder. Some unscrupulous people repeatedly abuse, exploit, and cheat others. We all may run across such people from time to time, and we need to learn how to protect ourselves. Robert Hare, an expert on psychopathy, concludes his book Without Con- science with a brief “survival guide” that may help you minimize your risk. He notes, for example, that we should be aware of the symptoms and interpersonal characteristics of psychopathy. We should be cautious in high-risk situations and know our own weaknesses. Hare’s advice may be extremely helpful to some- one who finds himself or herself trapped in a relationship with someone who is a psychopath. In fact, you may want to speak to a therapist or counselor to figure out why you have become involved in such an unequal, nonreciprocal relationship.

personality disorders CHAPTER 9 261

The disorders listed in Cluster A, especially schizoid and schizotypal personality disorders, have been viewed as pos- sible antecedents or subclinical forms of schizophrenia. They are defined largely in terms of minor symptoms that resemble the hallucinations and delusions seen in the full-blown disorder, as well as peculiar behaviors that have been observed among the first-degree relatives of schizophrenic patients.

The most important features of borderline personality disorder revolve around a pervasive pattern of instability in self-image, in interpersonal relationships, and in mood. Research regarding the causes of borderline personality disorder has focused on two primary areas. One involves the impact of chaotic and abusive families. The other is concerned with the premature separation of children from their parents. Both sets of factors presumably can lead to problems in emotional regulation.

Psychopathy and antisocial personality disorder are two different attempts to define the same disorder. The DSM-5 definition of ASPD places primary emphasis on social deviance in adulthood (repeated lying, physical assaults, reckless and irresponsible behavior). The concept of psychopathy places greater emphasis on emotional and interpersonal deficits, such as lack of remorse, lack of empathy, and shallow emotions.

Treatment for schizotypal and borderline personality disorders often involves the use of antipsychotic medication or antidepres- sant medication. Various types of psychological interventions, including dialectical behavior therapy, are frequently employed with borderline patients. People with antisocial personality disor- der seldom seek treatment voluntarily. When they do, the gen- eral consensus among clinicians is that it is seldom effective.

9.1 What is the difference between being eccentric and having a personality disorder? People who are unconventional are not necessarily disagreeable or difficult interpersonally. The concept of personality disorder, on the other hand, carries the assumption that the characteristic features by which they are defined are also associated with subjective distress or social impairment . . . (see pages 232–233).

9.2 In what ways are borderline and narcissistic personality dis- orders similar? People in both groups can be hypersensitive and self-centered, think- ing that others should be especially concerned with their needs and interests. When these expectations are not met, they may react with intense anger . . . (see page 241).

9.3 What are the advantages of a dimensional approach that would describe personality problems as variations on maladap- tive personality traits? This alternative perspective would minimize problems associated with comorbidity (a person meeting criteria for more than one di- agnostic category) and arbitrary cut-off points between normal and abnormal personality . . . (see pages 242–243).

9.4 Which personality disorders are least likely to change as a person gets older? Schizoid and schizotypal personality disorders are relatively intrac- table problems and are associated with enduring social isolation and occupational difficulties . . . (see page 247).

9.5 Why are personality disorders so difficult to treat? Many people with personality disorders are unable to recognize the nature of their problems. They may also be uncomfortable with the type of close, personal relationship that must be formed with a  therapist if psychological treatment is going to be successful . . . (see pages 250–251).

9.6 What is the difference between antisocial personality disor- der and psychopathy? The DSM-IV definition of antisocial personality disorder is focused largely on repeated conflict with authorities and failure to conform to social norms, while the definition of psychopathy places greater impor- tance on emotional deficits (lack of remorse, shallow emotions) and personality traits (impulsivity, grandiosity, lack of responsibility) . . . (see pages 255–256).

critical thinking review

The Big Picture

key terms antisocial personality

disorder 239 avoidant personality

disorder 241 borderline personality

disorder 240 cross-cultural psychology 248

dependent personality disorder 241

histrionic personality disorder 240

impulse control disorders 252 narcissistic personality

disorder 240

obsessive–compulsive personality disorder (OCPD) 241

personality 232 personality disorder (PD) 232 paranoid personality

disorder 238

psychopathy 255 schizoid personality

disorder 239 schizotypal personality

disorder 239

feeding and eating disorders

10

feeding and eating disorders CHAPTER 10 263

new diagnosis closely connected to the controversial question of whether obesity is a mental disorder. (DSM-5 says obesity is not a mental disorder.)

In this chapter, we briefly discuss other feeding and eating disorders but focus on anorexia nervosa and bulimia nervosa, two problems that traditionally have been called eating disorders. Some experts suggest that “dieting disorder” is a more accurate description. An undue emphasis on weight and shape is central to both of these problems, which typically affect adolescent and young adult women.

The most obvious characteristic of anorexia nervosa is ex- treme emaciation. The term anorexia literally means “loss of ap- petite,” but this is a misnomer. People with anorexia nervosa are hungry, yet they starve themselves nevertheless. Some unfortu- nate victims literally starve themselves to death.

Bulimia nervosa is characterized by repeated episodes of binge eating, followed by inappropriate compensatory behaviors such as self-induced vomiting, misuse of laxatives, or excessive exercise. Weight is in the normal range. Bulimia literally means “ox appetite” (hungry enough to eat an ox), but people with bulimia nervosa have an average appetite. Paradoxically, the problem may result from trying to maintain a weight below the body’s natural set point, an effort that re- sults in a yo-yo struggle with binge eating and compensation. Most sufferers view binge eating as a failure of control, but it really is their body’s natural reaction to unnatural weight suppression (Keel et al., 2007).

Popular culture in the United States is obsessed with physical appearance. We are told that “beauty is only skin deep,” but the entertainment, cosmetic, fashion, and diet industries are eager to convince young people that “looks are everything.” Perfect men are handsome, muscular, and successful. Perfect women are beautiful and thin—extremely thin. In fact, women’s thin- ness is equated with beauty, fitness, success, and ultimately with happiness. Given our national obsession with appearance, diet, and weight, is it surprising that many people, especially young women, become obsessed to the point of developing eating disorders?

Overview The DSM-5 lists six major types of disturbances in a new diag- nostic category called feeding and eating disorders, but we think DSM-5 was being too literal in grouping these problems together. Yes, they all involve eating, but . . . Three disorders—pica, rumi- nation disorder, and avoidant/restrictive food intake disorder— typically begin in infancy or childhood, often among children with intellectual disabilities. A fourth, binge-eating disorder is a

The Big Picture learning objectives

10.1 How can you tell if someone has an eating disorder?

10.2 How do images of women in the media

contribute to eating disorders?

10.3 Do men suffer from eating disorders?

10.4 What is binge-eating disorder?

10.5 Why do some girls and women develop eating disorders when others do not?

10.6 What treatments work for anorexia and bulimia?

10.7 Can eating disorders be prevented?

10

The images of women portrayed in advertising and the popular media contribute to the development of eating disorders.

264 CHAPTER 10 feeding and eating disorders

Both anorexia and bulimia are about 10 times more common among females than males, and they develop most commonly among women in their teens and early twenties. The increased incidence among young people reflects the contemporary, intense focus on young women’s physical appearance and the difficulties many adoles- cent girls have in adjusting to the rapid changes in body shape and weight that begin with puberty (Field & Kitos, 2010). While isolated cases of anorexia and bulimia have been reported throughout history, the problems received scientific attention only in recent decades (Fair- burn & Brownell, 2002; Striegel-Moore & Smolak, 2001). In fact, the term anorexia nervosa was coined in 1874, while bulimia nervosa was used for the first time only in 1979 (Heaner & Walsh, 2013).

According to the National Centers for Disease Control and Prevention, at any point in time, 44 percent of high school

females are attempting to lose weight compared with 15 per- cent of males (Serdula et al., 1993). Many adolescent boys want to gain weight in order to look bigger and stronger (see Eating Disorders in Males on p. xxx). Almost half of American women have a negative body image, particularly concerning their waist, hips, and/or thighs (Cash & Henry, 1995; see Figure 10.1). Eu- ropean American and Latina women report higher rates of body dissatisfaction than African Americans (Bay-Cheng et al., 2002; Grabe & Shibley-Hyde, 2006). Dissatisfaction increased from the 1980s to the 1990s among white women, but fortunately, levels of body dissatisfaction declined between the 1990s and 2000s for both white and black women (Cash et al., 2004). Perhaps fewer young women are falling victim to the popular media’s culture of thinness.

Eating Disorders in Males

Our culture clearly values different body types for males than for females. Adolescent boys often want to be bigger and stronger, not slimmer. Women rate themselves as being thin only when they are below 90 percent of their expected body weight. In contrast, men see themselves as thin even when they weigh as much as 105 percent of their expected weight (Ander- son, 2002). Surveys indicate that the majority of females want to lose weight, but males are about equally divided between those who want to lose weight and those who want to gain weight.

Some experts argue that pressures to be strong and muscular have created a new eating disorder among males. The problem, sometimes called reverse anorexia or the Adonis complex, is characterized by excessive emphasis on extreme muscularity and often accompanied by the abuse of anabolic steroids (Anderson, 2002; Ricciardelli & McCabe, 2004). You may recall that baseball slugger Mark McGwire was taking androstenedione (“andro,” an over-the-counter steroid hormone) when he broke the record for most home runs in a single season. McGwire’s popularity and success apparently contributed to growing steroid use among young males in the United States, where 3 percent to 12 per- cent of teenage boys have tried steroids (Ricciardelli & McCabe, 2004).

More realistic expectations about thinness surely contribute to the lower prevalence of anorexia and bulimia among males. However, men with these eating disorders are less likely to seek treatment than are women, perhaps because they are less likely to recognize the problem or feel more stigmatized because of it (Woodside et al., 2001). Men with anorexia or bulimia deviate far from male norms, and this can lead to rejection and stigmatiza- tion by other men, therapists, and even females with eating dis- orders. The stigma of being a man with an eating disorder also alters one common symptom of anorexia nervosa. Females with anorexia nervosa typically view their appearance positively, per- haps even with a degree of pride. In contrast, anorexia nervosa

can negatively affect the self-esteem of men, because weight and/or eating struggles are “unmanly” (Andersen, 1995).

Anorexia and bulimia are more common among certain sub- groups of males. Male wrestlers have a particularly high preva- lence of bulimia, a result of the intense pressure to “make weight”—to weigh below the weight cutoffs used to group competitors in a wrestling match. Eating disorders also are more common among gay men, who place more emphasis on appear- ance (Carlat, Camargo, & Herzog, 1997; Russell & Keel, 2002) and also endure minority stress (Kimmel & Mahalik, 2005).

Whether the ideal image is unrealistically thin or unrealistically muscular, cultural stereotypes about appearance can be risky for both males and females who internalize them.

Mark McGwire took androstenedione (“andro”), an over-the- counter steroid hormone, when he broke the single season home run record. Many teenage boys take steroids to build their bodies, a trend some consider to be a new eating disorder.

feeding and eating disorders CHAPTER 10 265

In this chapter, we discuss the symptoms of anorexia nervosa separately from those of bulimia nervosa, because they differ con- siderably. We combine the two disorders when reviewing diag- nosis, frequency, and causes, however, because they share many developmental similarities. For example, many people with an- orexia nervosa also binge and purge on occasion; many people with bulimia nervosa have a history of anorexia nervosa. When considering treatment, we again discuss the two disorders sepa- rately, reflecting the important differences in the focus and effec- tiveness of therapy for each disorder. We begin with a case study.

Serrita’s Anorexia Serrita was an attractive, well-dressed, and polite 15-year-old high school sophomore. An excellent student, her mother described Serrita as a “sweet girl who never gave me an ounce of worry— until now.” When she was first seen by a clinical psychologist for the treatment of anorexia nervosa, Serrita was 5 feet 2 inches tall and weighed 81 pounds. Serrita’s gaunt appearance was painfully obvi- ous to anyone who looked at her. Despite her constant scrutiny of her own body, however, Serrita firmly denied that she was too thin. Instead, she insisted that she looked “almost right.” She was still on a diet, and every day she carefully inspected her stomach, thighs, hips, arms, and face for any signs of fat. Serrita remained deathly afraid of gaining weight. She could recite every item of food she had consumed recently and discuss its caloric and fat content.

Serrita began her diet nine months earlier after visiting her family doctor, who told her that she could stand to lose a pound or two. Her diet began normally enough. She quickly lost the 6 pounds she wanted to lose, and without really planning to do so, she simply continued her diet. Her friends’ and family’s compli- ments soon turned into worried warnings, but privately Serrita was exhilarated. To her, the concerned remarks only proved that her diet was working. Secretly, she hoped that having a “great

body” would compensate for her perceived inadequacies. She wanted to look like the women in her favorite magazines, but she felt that she wasn’t a “cute, all-American girl”—she saw herself as too short, too dark, and her features as too sharp.

Serrita’s breakfast consisted of one slice of dry wheat toast and a small glass of orange juice. Lunch was either an apple or a small salad without dressing. In between meals, Serrita drank sev- eral diet colas, which helped control her constant, gnawing appe- tite. Dinner typically was a family meal. Serrita picked at whatever she was served. Sometimes her parents would plead with her to eat more, and Serrita would eat a bit to appease them. On occa- sion, perhaps once a week, Serrita forced herself to vomit after dinner, because she felt that her parents made her eat too much.

Serrita’s parents became so concerned that they made her go to see her family physician. The physician also was very worried about Serrita’s low weight, and she discovered that Serrita had not menstruated in over six months. The physician said that Ser- rita was suffering from anorexia nervosa. She immediately made a referral to a psychologist as well as to a nutritionist, who, the phy- sician hoped, would correct Serrita’s extreme views about dieting.

In talking with the psychologist, Serrita agreed that she under- stood why everyone was concerned about her health. She knew about anorexia nervosa, which she realized was a serious prob- lem. Serrita even hinted that she knew that she was suffering from anorexia nervosa. Nevertheless, she steadfastly denied that she needed to gain weight. Although she was happy to talk with the psy- chologist, she was not prepared to change her eating habits. Serrita was deathly afraid that eating even a little more would cause her to “turn into a blimp.” She was proud of her mastery of her hunger. She was not about to give up the control she had fought so hard to gain.

Symptoms of Anorexia Serrita showed all the classic symptoms of anorexia nervosa: emaciation, a disturbed view of her body, and an intense fear of gaining weight. She also had problems commonly associated with anorexia nervosa but not defining symptoms including the cessation of menstruation, obsessive preoccupation with food, occasional purging, and a “successful” struggle for control over persistent hunger. Additional difficulties sometimes associated with anorexia nervosa include mood disturbance, sexual prob- lems, a lack of impulse control, and medical issues.

Significantly Low Weight The most obvious and most dangerous symptom of anorexia ner- vosa is a significantly low weight. Anorexia nervosa often begins with a diet gone awry, as it did with Serrita. Weight falls below normal and may plummet dangerously.

DSM-5 contains no formal cutoff as to how thin is too thin, but suggests a body mass index (BMI)1 under 18.5 is a useful

figure 10.1 Percentage of females reporting that they were “very or mostly dis- satisfied” with specific physical attributes in a national sample of women aged 18 to 70. Source: Cash, Thomas and Patricia Henry. 1995. Women’s Body Images: The Results of a National Survey in the U.S.A. Sex Roles; 33: 19–28.

Weight

60

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nt ag

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f w

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en re

p o

rt in

g d

is sa

ti sf

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Face Height Hair Upper torso

Muscle tone

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11.7 13.4

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40

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36.9

46.0 47.4

1To calculate the body mass index: (1) Multiply weight in pounds by 700; (2) divide this number by height in inches; (3) divide this second number by height in inches. BMI percentiles by age are available for children and adolescents, whose low weight may be due to failure to make expected gains rather than weight loss.

266 CHAPTER 10 feeding and eating disorders

Amenorrhea Amenorrhea, the cessation of menstruation, used to be consid- ered as a core symptom of anorexia nervosa in females. However, amenorrhea typically is a reaction to the loss of body fat and as- sociated physiological changes, not a symptom that precedes anorexia (Pinheiro et al., 2007). The DSM-5 dropped this di- agnostic criterion for this reason, and because amenorrhea does not differentiate between women who meet other criteria for an- orexia. Menstrual irregularities also are common in bulimia (Attia & Roberto, 2009; Pinheiro et al., 2007; Wilfley et al., 2008).

Medical Complications Anorexia nervosa can cause a number of medical complications. People with anorexia commonly complain about constipation, ab- dominal pain, intolerance to cold, and lethargy. Some complaints stem from the effects of semistarvation on blood pressure and body temperature, both of which may fall below normal. In addition, the skin can become dry and cracked, and some people develop la- nugo, a fine, downy hair, on their face or trunk of their body. Other medical difficulties may include anemia, infertility, impaired kid- ney functioning, cardiovascular problems, dental erosion, and bone loss (Mitchell & Crow, 2010). A particularly dangerous medication complication is an electrolyte imbalance, a disturbance in the lev- els of potassium, sodium, calcium, and other vital elements found in bodily fluids. Electrolyte imbalance can lead to cardiac arrest or kidney failure. Anorexia nervosa may begin with the seemingly harmless desire to be a bit thinner, but the eating disorder can lead to serious health problems, including death.

Struggle for Control Some people with anorexia act impulsively, but more are conform- ing and controlling. Some theorists speculate that the disorder actually develops out of a sense of having no control. Excessively compliant “good girls” may find that obsessively regulating their diet allows them to be in charge of at least one area of their lives (Bruch, 1982). Certainly, many young people with anorexia nervosa take great pride in their self-denial, feeling like masters of control.

Comorbid Psychological Disorders Anorexia nervosa is associated with other psychological prob- lems, including obsessive–compulsive disorder and obsessive– compulsive personality disorder (Halmi, 2010). People with anorexia nervosa are obsessed with food and diet, and they of- ten follow compulsive eating rituals. However, a unique study found that such behavior can result from starvation. In this study, 32 World War II conscientious objectors fulfilled their military obligation by voluntarily undergoing semistarvation for 24 weeks. (The researchers wanted to learn about the effects of starvation on military personnel in the field.) As the men lost more and more weight, they developed extensive obsessions about food and compulsive eating rituals. For many, the obsessions and compulsions continued long after they returned to their normal weight (Keys et al., 1950). This suggests that obsessive–compulsive

indicator in adults. The average victim is far more emaciated, 25 to 30 percent below normal body weight. Many anorexics are not treated until their weight loss becomes life threatening. In fact, about 5 percent of people with anorexia nervosa die of starvation, suicide, or medical complications stemming from their extreme weight loss (Steinhausen, 2002).

Fear of Gaining Weight An intense fear of gaining weight or becoming fat is the second de- fining characteristic of anorexia. The fear of gaining weight presents particular problems for treatment. A therapist’s encouragement to eat more can terrify someone who fears that relaxing control, even just a little, will lead to a total loss of control. Ironically, the fear of gaining weight is not soothed by weight loss. In fact, the fear may grow more intense as the individual loses more weight (APA, 2013).

Disturbance in Experiencing Weight or Shape The third and final defining symptom of anorexia nervosa in- volves a disturbance in how weight or shape is experienced. People with anorexia nervosa usually do not recognize their ema- ciation for what it is. Many steadfastly deny problems with their weight. Even when confronted with their own withered image in a mirror, some people with anorexia nervosa insist that their weight is not a problem. Sometimes this may include a distorted body image, an inaccurate perception of body size and shape. The following excerpt, which we received anonymously from a stu- dent, illustrates the disturbance in experiencing weight or shape.

I’ll try to explain how a person with an eating disorder sees a distorted image of herself. It’s almost like she sees herself as bloated—of course she sees herself, she recognizes herself, but as bigger than usual. Also, the skinnier she gets, the more she notices fat deposits around the waist, under the arms, etc., be- cause the more fat is lost, the more attention is drawn to the little bit of fat that still exists. Also, it’s the point of reference in the background that may sometimes be distorted. She looks in the bathroom mirror and thinks, “Did I take up that much space against this wall yesterday?”

Isabelle Caro was a French model and actress who allowed her emaciated image to be used in an Italian advertising campaign against anorexia. She died on November 17, 2010, due to complications associated with her eating disorder.

feeding and eating disorders CHAPTER 10 267

uncomfortable, sickened by her lack of control, and terrified of gaining weight. To compensate, she would walk across the street to an empty bathroom in the psychology department. There, she forced herself to vomit by sticking her finger down her throat.

The vomiting brought relief from the physical discomfort, but it did not relieve her shame. Michelle was disgusted by her ac- tions, but she could not stop herself. In fact, the pattern of binge eating and purging had been going on for most of the school year. Michelle decided to seek treatment only when a friend from her psychology class discovered her purging in the bathroom. The friend also had a history of bulimia nervosa, but she had gotten her eating under control. She convinced Michelle to try therapy.

Michelle’s eating problems began when she was in high school. She had studied ballet since she was eight years old, and with the stern encouragement of her instructor, she had struggled to maintain her willowy figure as she became an adolescent. At first she dieted openly, but her parents constantly criticized her inad- equate eating. To appease them, Michelle occasionally would eat a more normal meal, but she often forced herself to vomit shortly afterward. When she was a junior in high school, Michelle’s parents took her to a psychologist, who treated her for anorexia nervosa. She was 5 feet 6 inches tall, but she weighed only 95 pounds. Mi- chelle was furious and refused to talk in any depth with the thera- pist. She allowed herself to gain a few pounds—to about 105—only to convince her parents that she did not need treatment.

Michelle’s weight eventually stabilized around 105 pounds. Even though she was very thin, Michelle continued to count every calorie at every meal every day. Throughout college, she starved herself all week so she could eat normally on dates during the weekend. Occasionally, she forced herself to vomit after eating too much, but she did not see this as a big problem. Until the previous summer, she had maintained her weight near her goal of 105 pounds. Over the summer, however, Michelle relaxed her diet as she “partied” with old friends. She gained about 15 pounds, a healthy but still quite thin weight for her height and body type. When she returned to college, however, Michelle grew disgusted with her appearance and fearful of gaining even more weight.

Michelle tried to lose weight, but she met with little success. She started to purge more frequently in a desperate attempt to “diet,” but she soon found herself binge eating more frequently, too. Michelle was extremely frustrated by her “lack of self-con- trol.” Although she now recognized her past problems with an- orexia nervosa, Michelle openly longed for the discipline she had once achieved over her hunger and diet.

Michelle was a bright, attractive, and successful young woman, but she felt like a failure and a “fake.” She longed to have a boyfriend but never found one despite many casual dates. She was intensely, if privately, competitive with her girlfriends. She wanted to be more beautiful and intelligent than other girls, but she inevitably felt inferior to one classmate or another. She was determined at least to be thinner than her girlfriends, but she felt that she had lost all control over this goal. Michelle pretended to be happy and normal, but secretly, she was miserable.

behavior may be a reaction to starvation, not a risk factor for anorexia.

Most people with anorexia nervosa also show symptoms of depression, such as sad mood, irritability, insomnia, social with- drawal, and diminished interest in sex (Halmi, 2010). Like obsessive– compulsive behavior, however, depression can either be a cause of or a reaction to the eating disorder (Vögele & Gibson, 2010).

Finally, anorexia often co-occurs with the symptoms of buli- mia. In some cases, purging follows episodes of binge eating. In other cases, purging may be a means of further controlling eating that already is dramatically restricted. People with anorexia ner- vosa who do not binge eat or purge generally are better adjusted on measures of their mental health—for example, they have lower rates of depression (Braun, Sunday, & Halmi, 1994).

Symptoms of Bulimia Bulimia nervosa and anorexia nervosa, although different, share many similarities. One connection is that people with bulimia nervosa have often a history of anorexia nervosa, as in the follow- ing case study.

Michelle’s Secret Michelle was a sophomore at a state university when she first sought help for a humiliating problem. Once or twice a week, she fell into an episode of uncontrollable binge eating followed by self-induced vomiting. When Michelle was alone and feel- ing bad, she would buy a half-gallon of ice cream and perhaps a bag of cookies and bring the food back to her room, where she secretly gorged herself. The binge brought Michelle some com- fort at first, but by the time she was finished, she felt physically

Conscientious objectors participating in a study of semistarvation during World War II. Many starving men developed obsessions about food simi- lar to those sometimes found in anorexia nervosa.

268 CHAPTER 10 feeding and eating disorders

of fasting. The binge initially may alleviate some unhappy feel- ings, but physical discomfort, shame, and fear of gaining weight quickly return (Berg, Crosby, Cao, Peterson, Engel, Mitchell, and Wonderlich, 2013).

A key diagnostic feature is a sense of lack of control during a binge. Some individuals experience a binge as a “feeding frenzy,” where they lose all control, eating compulsively and rapidly. Others describe a dissociative experience, as if they were watch- ing themselves gorge. But the lack of control is not absolute. For example, people with bulimia can stop a binge if they are inter- rupted unexpectedly. In fact, as the disorder progresses, some people feel more in control during a binge but unable to stop the broader cycle of binge eating and compensatory behavior.

Inappropriate Compensatory Behavior Most people with bulimia nervosa engage in purging, designed to eliminate consumed food from the body. The most common form of purging is self-induced vomiting (APA, 2013). Other inappropri- ate compensatory behaviors include the misuse of laxatives, diuretics (which increase the frequency of urination), and, most rarely, en- emas. Ironically, purging has only limited effectiveness in reducing caloric intake. Vomiting prevents the absorption of only about half the calories consumed during a binge, and laxatives, diuretics, and enemas have few lasting effects on calories or weight (Kaye et al., 1993).

Other inappropriate compensatory behaviors include ex- treme exercise or rigid fasting. The extent to which these actions actually compensate for binge eating also is questionable, given what we know about the body’s biological regulation of weight (Brownell & Fairburn, 1995). DSM-5 indicates that binge eating and compensatory behavior must occur once a week, on average, for at least three months.

Excessive Emphasis on Weight and Shape Self-evaluation is unduly influenced by body shape and weight in bulimia nervosa, a symptom shared with anorexia nervosa (see Table 10.1). Self-esteem, and daily routines, can center

Michelle’s frequent struggles with binge eating, her self- induced vomiting and purging, and her undue focus on her weight and figure are the core symptoms that define bulimia nervosa. Depression also is commonly associated with the disorder, along with possible medical complications. Unlike anorexia, weight is in the normal range in bulimia nervosa.

Binge Eating The DSM-5 defines binge eating as consuming an amount of food that is clearly larger than most people would eat under simi- lar circumstances in a fixed period of time, for example, less than two hours. There have been some attempts to define a binge more objectively, such as eating more than 1,000 calories, or subjectively, such as based on the individual’s appraisal. Variations in normal eat- ing complicate these alternative definitions, however. Eating a very large number of calories may be normal under certain circumstances (think: Thanksgiving). Others may consider eating two cookies to be a “binge.” Thus, the DSM-5 ultimately relies on clinical judgment.

Sadly, many inappropriate eating behaviors border on being statistically normal—and clearly unhealthy—in our food- and weight-obsessed society. Over 35 percent of people report oc- casional binge eating. Large numbers of people also report that they fast (29 percent) and use self-induced vomiting (8 percent) or laxatives (over 5 percent) in an attempt to compensate for their eating (Fairburn & Beglin, 1990).

Binges may be planned in advance, or they may begin spon- taneously. In either case, binges typically are secret. Most people with bulimia nervosa are ashamed and go to elaborate efforts to conceal their binge eating. During a binge, the individual typi- cally eats very rapidly and soon feels uncomfortably full. The per- son often selects binge foods they would not ordinarily eat. Foods also may be selected for smooth texture to make vomiting easier, one reason why ice cream is a popular binge food.

Binge eating is commonly triggered by an unhappy mood, which may begin with an interpersonal conflict, self-criticism about weight or appearance, or intense hunger following a period

table 10.1 Anorexia Nervosa and Bulimia Nervosa: Key Differences and Similarities

Issue Anorexia Nervosa Bulimia Nervosa

Differences

Eating/weight Extreme diet; below minimally normal weight Binge eating/compensatory behavior; normal weight

View of disorder Denial of anorexia; proud of “diet” Aware of problem; secretive/ashamed of bulimia

Feelings of control Comforted by rigid self-control Distressed by lack of control

Similarities

Self-evaluation Unduly influenced by body weight/shape Unduly influenced by body weight/shape

Comorbidity of AN/BN Some cases of AN also binge and purge Many cases of BN have history of AN

SES, age, gender Prevalent among high SES, young, female Prevalent among high SES, young, female

feeding and eating disorders CHAPTER 10 269

the front teeth. In severe cases, teeth can become chipped and ragged looking. Another possible medical complication is the enlargement of the salivary glands, a consequence that has the ironic effect of making the sufferer’s face appear puffy. As in an- orexia nervosa, potentially serious medical complications can re- sult from electrolyte imbalances. Finally, rupture of the esophagus or stomach has been reported in rare cases, sometimes leading to death (Mitchell & Crow, 2010).

Diagnosis of Feeding and Eating Disorders As noted, DSM-5 lists six types of feeding and eating disorders. Pica is the eating of nonnutritive substances like paper or dirt, and is found commonly among children with intellectual dis- abilities. Rumination disorder involves repeated regurgitation of food, sometimes with rechewing, and often occurs in infants, sometimes in the context of neglect and/or intellectual disabili- ties. Avoidant/restrictive food intake disorder also occurs mostly in infants and is characterized by an apparent lack of interest in food. All of these problems appear to be relatively rare and not well understood.

Binge-eating disorder, episodes of binge eating without compensatory behavior, is a new diagnosis in DSM-5. Binge eat- ing is associated with a number of psychological and physical dif- ficulties, including obesity, often defined as a BMI greater than 30 (Marcus & Wildes, 2009). The new diagnosis is controversial in part because of its link with obesity (see Thinking Critically about DSM-5).

Anorexia nervosa is defined by the three symptoms described earlier (see DSM-5 criteria for Anorexia Nervosa on p. xx). DSM-5 also includes two subtypes of anorexia nervosa. The restricting type

around weight and diet. Some people are exhilarated by posi- tive comments or interest in their appearance, but self-esteem plummets if a negative comment is made or if someone else draws more attention. Others constantly criticize their ap- pearance, and the struggle with bulimia only adds to self-den- igration. In all cases, the individual’s sense of self is linked too closely to appearance instead of personality, relationships, or achievements.

Comorbid Psychological Disorders Depression is common among individuals with bulimia nervosa. Some individuals become depressed prior to developing the eat- ing disorder, and the bulimia may be a reaction to the depression. In many instances, however, depression begins at the same time as or follows the onset of bulimia nervosa (Braun, Sunday, & Halmi, 1994). In such circumstances, the depression is likely to be a reaction to the bulimia. In fact, depression often lifts follow- ing successful treatment (Mitchell et al., 1990). Whether depres- sion is an effect or cause of bulimia, eating disturbances are more severe and social impairment is greater when the two problems are comorbid (Stice & Fairburn, 2003).

Other disorders that may co-occur with bulimia nervosa in- clude anxiety disorders, personality disorders (particularly bor- derline personality disorder), and substance abuse, particularly excessive use of alcohol and/or stimulants. Although each of these psychological difficulties presents special challenges in treating bulimia, the comorbidity with depression is most common and most significant (Halmi, 2010).

Medical Complications A number of medical complications can result from bulimia ner- vosa. Repeated vomiting can erode dental enamel, particularly on

Thinking CriTiCally about DSM-5

Is Binge Eating a Mental Disorder? Is Obesity?

DSM-5 includes the new diagnosis, binge-eating dis-order. The disorder is defined by binge eating just like in bulimia (and, like bulimia, occurring once a week on average for 3 months), except without compensa- tory behavior. In addition, the binges must involve three of five symptoms: rapid eating, feeling uncomfortably full af- terward, binge eating when not hungry, feeling embarrassed while eating, or feeling disgusted afterward. Yes. People with bulimia often report these subjective symptoms too, but un- like binge eating, they do not have to be present to make the diagnosis.

The inclusion of binge-eating disorder in DSM-5 has been criti- cized by some. Allen Frances, the psychiatrist who chaired the

previous DSM revision and vocal DSM-5 critic wrote in his blog: “Excessive eating 12 times in three months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness . . .” However, most experts seem to have embraced the new diagnosis, along with DSM-5.

In contrast to binge-eating disorder, DSM-5 decided that obe- sity is not a mental disorder. Why? Obesity clearly is harmful. Obesity is a risk factor for heart disease, diabetes, kidney dis- ease, sleep apneas, several kinds of cancer, and early mortality. Obesity accounts for over 9% of health expenses and is ex- pected to consume 16% by 2030. Obesity also is linked with an increased risk for mood disorders, anxiety disorders, eating

continued

270 CHAPTER 10 feeding and eating disorders

disorders, and personality disorders, although it is not clear what is cause and what is effect (Marcus & Wildes, 2009).

But calling obesity a mental disorder is controversial. Suddenly, 32.2% of adults and 17.1% of children in the United States would have a mental disorder (Ogden, Carroll, Curtin, McDowell, Tabak, & Flegal, 2006). (These people would then become eligible for medical insurance reimbursement. Hmmm. Maybe DSM would like them to have “mental disorder.”) Others question our soci- ety’s castigation of obese people. Why further stigmatize over- weight people by saying they have a mental disorder?

We think these are good points, but let’s circle back to binge-eating disorder. DSM-5 notes that binge-eating disorder “may also be as- sociated with an increased risk for weight gain” (p. 352). Well, yes. Up to half of people seeking weight loss treatment report binge eating, and a recent study found that “clinically meaningful” (twice a week or more) binge eating occurred among 78.2 of 45,477 obese (BMI> 30) veterans (Higgins et al., in press). This leads us to wonder: Do the other 21.8% engage in some other problematic eating behavior? Will this become a mental disorder in future

versions of the DSM? In fact, DSM-5 includes “night eating syn- drome” in its list of “Other specified feeding or eating disorders.”

The DSM-5 tries to distinguish binge-eating disorder from obe- sity in other ways. The manual says that people with binge-eating disorder are more focused on weight and have more psycho- logical problems than obese individuals. But weight concerns and emotional struggles are common among most overweight people too. DSM-5 also says that binge eating responds to treat- ment, while obesity is hard to change. True, but should the man- ual drop anorexia as a mental disorder because it is hard to treat?

All of this leads us to wonder: Is binge-eating disorder a way of letting obesity in through DSM-5’s backdoor?

Postscript: The very day that we wrote this, the American Medi- cal Association officially recognized obesity as a disease. Among the issues involved in this decision were whether obesity is a matter of self control, whether the disease label would stig- matize—or destigmatize—obesity, labeling large numbers of people as sick, and, ahem, eligible for insurance reimbursement (New York Times, June 18, 2013).

includes people who have not engaged in binge eating or purg- ing in the last three months. In contrast, the binge eating/purging type is defined by regular binge eating and purging. The DSM-5 kept this distinction, even though the validity of the subtypes is questionable: They do not differ in terms of comorbidity, recov- ery, relapse, or mortality (Wonderlich et al., 2007). Moreover, an eight-year longitudinal study found that 62 percent of the former restrictors met diagnostic criteria for binge eating/purging, and only 12 percent of the restrictors had never regularly engaged in binge eating or purging (Eddy et al., 2002).

Bulimia nervosa is defined by the four symptoms described earlier (see “DSM-5: Bulimia Nervosa””). Previous subtypes of bulimia based on the presence or absence of purging were not

MyPsychlab ViDEO CaSE

Anorexia Nervosa

NATASHA

“I was never skin and bones. Never. I wanted to be. Had I not gone inpatient, I would have been.”

Watch the Video Natasha: Anorexia on

MyPsychLab

As you watch Natasha, listen how her perfec- tionism and control issues focus on her weight and appearance.

criteria for Anorexia Nervosa

A. Restriction of energy intake relative to requirements, lead- ing to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

B. Intense fear of gaining weight or of becoming fat, or persis- tent behavior that interferes with weight gain, even though at a significantly low weight.

C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of

recognition of the seriousness of the current low body weight.

(F50.01) Restricting type: During the last 3 months, the indi- vidual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.

(F50.02) Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enem as).

DSM-5

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

feeding and eating disorders CHAPTER 10 271

supported by research (Wilfley et al., 2008), so DSM-5 dropped this categorization.

Frequency of Anorexia and Bulimia Estimates of the frequency of anorexia and bulimia vary, but both disorders appear to have increased since the 1960s and 1970s. Figure 10.2 illustrates the surge in new cases of anorexia nervosa based on a compilation of evidence from Northern Europe (Hoek & van Hoeken, 2003). The annual incidence, the number of new cases each year, of anorexia nervosa rose from 1 case per million people in 1930–1940 to 54 cases per million people in 1995– 1996. Figure 10.2 also shows that anorexia nervosa is rare in the general population with the annual incidence stabilizing in recent decades. Anorexia is far more common among certain groups, however, particularly young women, where the incidence still may be increasing (Keel, 2010). DSM-5 indicates that 12 month prevalence of anorexia nervosa is 0.4 among females, similar to a 0.9 estimate based on a recent U.S. national survey (Hudson et al., 2007). Anorexia nervosa also occurs among males, but the disorder is about 10 times more common among women than men. Establishing the exact prevalence in males is difficult, be- cause only a few cases are identified even in large national surveys (Hudson et al., 2007).

criteria for Bulimia Nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour

period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.

2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

DSM-5

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

MyPsychlab ViDEO CaSE

Bulimia Nervosa

JESSICA

“It started out with a diet for me . . .”

Watch the Video Stacy: Binge Eating

Disorder on MyPsychLab

As you watch the video, listen for Jessica’s struggles with appearance and weight

and how they were magnified—sometimes very directly—by her efforts to pursue a career in the performing arts.

figure 10.2 Annual Incidence of Anorexia Nervosa in Northern Europe from 1931 to 1996 Anorexia nervosa increased dramatically in the 1960s and 1970s, as the ideal media image of women grew thinner. Considerably higher rates are found among population subgroups, particularly young women. Source: Hoek, W.H. 2003. The Distribution of Eating Disorders. In Eating Disorders and Obesity: A Compre- hensive Handbook. Guilford Press.

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Recent decades have also witnessed a torrent of new cases of bulimia nervosa. Changes in the frequency of bulimia nervosa are difficult to document, however, because the diagnostic term was introduced only in 1979. Instead, investigators have examined co- hort effects in prevalence rates. A cohort is a group that shares some features in common, for example, year of birth; thus, cohort effects are differences that distinguish one cohort from another.

272 CHAPTER 10 feeding and eating disorders

surveys (Hudson et al., 2007). Like anorexia, bulimia is about 10 times more common in women than men. Binge-eating disorder and occasional binge eating are even more common, with a re- spective lifetime prevalence of 3.5 percent and 4.9 percent among women and 2.0 percent and 4.0 percent among men (Hudson et al., 2007). Some evidence suggests that bulimia may be de- creasing, but evidence is variable, with declines perhaps linked to changing cultural standards of beauty (Keel, 2010). Finally, we should note again the overlap between anorexia nervosa and bu- limia nervosa. About 50 percent of all people with anorexia ner- vosa engage in episodes of binge eating and purging (Garfinkel et al., 1995), and many cases of bulimia nervosa have a history of anorexia nervosa (Wonderlich et al., 2007).

Standards of Beauty Many scientists believe that this huge difference in the prevalence of eating disorders between men and women is explained by gen- der roles (Field & Kitos, 2010). Popular attitudes about women in the United States tell us that “looks are everything,” and thin- ness is essential to good looks. In contrast, young men are valued as much for their achievements as for their appearance, and the ideal body type for men is considerably larger and more muscular than for women (see Critical Thinking Matters). In fact, women are much more likely than men to have a negative body image, and that disparity has been growing over time (Feingold & Maz- zella, 1998).

The surge in eating disorders among women appears to be partially explained by changing standards of beauty. Playboy centerfolds and Miss America Beauty Pageant contestants— cultural icons but dubious role models for young women— provide the statistics. Between 1959 and 1988, their ratio of weight to height declined dramatically. In fact, 69 percent of Playboy centerfolds and 60 percent of Miss America contes- tants weigh at least 15 percent below expected weight for their height (Garner et al., 1980; Wiseman et al., 1992). Marilyn Monroe, the movie idol of the 1950s, is chunky according to today’s “culture of thinness.”

Standards of beauty are relative, not absolute. Today, eating disorders are much more common in North America, Western

Figure 10.3 portrays birth cohort effects in lifetime preva- lence rates of bulimia nervosa among a large sample of American women who were born either before 1950, between 1950 and 1959, or in 1960 or after. The figure clearly indicates substantial cohort effects. The lifetime prevalence of bulimia nervosa was far greater among the women born after 1960 than it was for those born before 1950. The risk for women born between 1950 and 1959 was intermediate between the two (Kendler et al., 1991). Figure 10.3 also shows that the risk of developing bulimia de- clines with increasing age, at least among older cohorts. A recent study of a national U.S. sample also found this declining risk with age and replicated the cohort effects (Hudson et al., 2007). Thus, the surge in bulimia nervosa—some say an epidemic—is due to dramatic increases among women born in more recent years. Not coincidentally, cultural standards of beauty changed for this gen- eration of women.

Bulimia nervosa has a lifetime prevalence of 1.5 percent among U.S. women according to both DSM-5 and national

figure 10.3 The lifetime cumulative risk for developing buli- mia nervosa is far greater for women born after 1960 than for women born before 1950. The risk for developing the disorder decreases with age, at least among the earlier birth cohort. Later birth cohorts have not yet moved through the entire age of risk. Source: K. S. Kendler, C. MacLean, M. Neale, R. Kessler, A. Heath, and L. Eaves. The Genetic Epidemiology of Bulimia Nervosa. American Journal of Psychiatry. Dec 1991; 148: 1627–1637. Reprinted with permission from the American Journal of Psychiatry (Copyright © 1991). American Psychiatric Association. All Rights Reserved.

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Actress Jessica Biel was Esquire magazine’s “sexiest woman alive.” She is athletic, shapely, and fit, but not abnormally thin.

feeding and eating disorders CHAPTER 10 273

Age of Onset Both anorexia and bulimia nervosa typically begin in adoles- cence or early adulthood (Hudson et al., 2007). The adolescent onset has provoked much past speculation about their cause, including hormonal changes (Garfinkel & Garner, 1982), au- tonomy struggles (Minuchin, Rosman, & Baker, 1978), and

Europe, and industrialized Asian countries; bulimia may be com- pletely culture bound (Keel & Klump, 2003). In other cultures, women who are more rounded are considered to be more beauti- ful. In Third World countries, where food is scarce, being larger is a symbol of beauty and success. In industrialized nations, the opposite is true. As the saying goes, “You can never be too rich or too thin.”

CriTiCal Thinking matters

The Pressure to Be Thin

Critical thinking matters in the classroom—and in everyday life. Consider how young women (and men) embrace standards of beauty based on images in the media, and, in turn, apply fashion model standards to themselves and others.

The images are everywhere. Super-thin models routinely grace the cover and inside of fashion magazines. The average fash- ion model is 5'11" and 117 pounds; the average woman in the United States is 5'4" and 140 pounds. Television and movie actresses are not only talented and beautiful, but also excep- tionally thin. Advertisements in all kinds of media for all kinds of products use images of sexy, beautiful, and very thin women, im- ages that often are altered not only to erase blemishes, but also to lengthen legs or otherwise distort body shape. Even girls’ dolls are unrealistically thin and beautiful. The ubiquitous Barbie doll has a shape that translates into a 39–18–33 figure in human equivalents. (In 1994, Dolly Parton claimed that she measured 40–20–36.) And real-life GI Joe would have a 55" chest and a 27" bicep. (At his bodybuilding peak, Arnold Schwarzenegger had a 57" chest and 22" biceps.)

The pressure to be thin greatly affects women who make their careers as actresses, models, and singers. The Brazilian model Ana Carolina Reston died of complications due to anorexia in 2006. (In the same year, the Spanish government banned too- thin models from a popular fashion show.) The dubious “who’s who” of women in the popular media who have publicly admit- ted to having an eating disorder (often in an attempt to encour- age healthier body images among the girls and women who admire them) includes actresses Mary-Kate Olsen, Demi Lovato, and Kate Winslet; fashion model Carre Otis; singers Lady Gaga, Ashlee Simpson, Paula Abdul, and Victoria Beckham (Posh Spice of the Spice Girls); and Oprah Winfrey.

Psychological studies repeatedly show that exposure to images of super-thin women increases body image dissatisfaction among girls and young women (Halliwell & Dittmar, 2004). Yet, young women face contradictory messages when told, “Beauty is only skin deep.” For one, both extensive psychological research and everyday experience repeatedly tell us that attractiveness does matter, not only to romantic attraction (although men prefer a more curvaceous figure than women think they like), but also appearance matters in the evaluations of same-gender peers, teachers, employers, and on and on. And even as some public health advocates battle the culture of thinness, others tell young people—rightly—to be careful about what you eat, to not eat too much, and to try to lose weight. Obesity is a much more common public health problem than eating disorders.

So where does critical thinking come in? Critical thinking is about thinking independently. Appearance does matter, but few of us, female or male, can hope to look like models or movie stars. After all, these professionals literally are one in a million (or a billion). The stars of popular media devote much of their life to their ap- pearance, and they still need the help of makeup, camera angles, creative fashions, and electronic “corrections.” Health matters, too, and exercise is a great way to promote health, maintain an attractive physical appearance, and remember that your body is good for something other than being looked at. And in the end, most people are more impressed by who you are than what you look like. This is a useful reminder when we start to think critically— instead of using critical thinking—in evaluating our own weight and shape.In 1994, Dolly Parton claimed that she measured 40-20-36.

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• Eating disorders are even more common among young women working in fields that emphasize weight and appear- ance, such as models, ballet dancers, and gymnasts (Bryne, 2002).

• Young women are particularly likely to develop eating disor- ders during adolescence and young adult life, an age during which our culture places a particular emphasis on appear- ance, beauty, and thinness (Hoek, 2002).

• Eating disturbances are more common among young women who report greater exposure to popular media, endorse more gender-role stereotypes, or internalize societal standards about appearance (Grabe, Ward, & Hyde, 2008).

• Eating disorders are more common among white women, who are more likely to equate thinness with beauty, versus African American women. Eating disorders also may be in- creasing among well-to-do African Americans, who increas- ingly hold the thinness ideal (Field & Kitos, 2010; Wildes, Emery, and Simons, 2001).

• Eating disorders are far more prevalent in industrialized so- cieties, where thinness is the ideal, than in nonindustrialized societies, where a more rounded body type is preferred (Keel & Klump, 2003).

• The prevalence of eating disorders is higher among Arab and Asian women living or studying in Western countries than among women living in their native country (Hoek, 2002).

These facts make it clear that adolescent girls and young women are at risk for developing eating disorders, in part because they attempt to shape themselves, quite literally, to fit the image of the ideally proportioned, thin woman. We should note, how- ever, that the culture of thinness plays a stronger role in the devel- opment of bulimia than anorexia. Cases of anorexia nervosa are found in the historical literature, occur in non-Western cultures, and appear to have increased less than cases of bulimia nervosa in response to cultural ideals of thinness (Keel & Klump, 2003).

Of course, not every woman in the United States develops an eating disorder, so other factors must interact with culture to produce eating disorders (Striegel-Moore & Bulik, 2007). One basic influence is the individual’s internalization of the ideal of thinness (Cafri et al., 2005). Same-gender peers can influence in- ternalization (Field & Kitos, 2010; Keel, Forney, Brown, Heath- erton, 2013), and so can popular media. In one study, ninth- and tenth-grade high school girls randomly received a free subscrip- tion to Seventeen magazine. One year later, those who received the magazine reported increased negative affect, but only if their body image was negative and they felt pressure to be thin when the study began (Stice, Spangler, & Agras, 2001). These girls ap- parently were more vulnerable to the media’s “thin” message.

TROuBLED FAMILy RELATIONShIPS Troubled family relation- ships may also increase vulnerability to the culture of thinness (Jacobi et al., 2004). Young people with bulimia nervosa report

various sexual problems (Coovert, Kinder, & Thompson, 1989). A more simple explanation is the natural and normal changes in adolescent body shape and weight. Weight gain is normal dur- ing adolescence, but the addition of a few pounds can trouble a young woman focused on the numbers on her scale. Breast and hip development not only change body shape, but they also af- fect self-image, social interaction, and the fit of familiar clothes. Early pubertal timing is a risk factor for anorexia, supporting the importance of self-evaluation and social comparison as girls’ shape develops normally in early adolescence (Jacobi & Fittig, 2010).

Weight and dieting become less of a concern, and disordered eating declines, as adolescent girls become women. Changes are particularly sharp following marriage and parenthood (Keel et al., 2007). Men, however, become more concerned with weight as they age. As men’s metabolism slows with increasing age, losing weight becomes more of a worry than gaining weight.

Causes of Anorexia and Bulimia The culture of thinness clearly contributes to the high rate of eating disorders today. However, other social, psychological, and biological risk factors must play a role, because not every young woman suffers from these problems.

Social Factors Standards of beauty and the premium placed on young women’s appearance contribute to causing eating disorders. This conclu- sion is supported by the following epidemiological evidence and other research:

• Eating disorders are far more common among young women than young men (Hoek & van Hoeken, 2003). As Striegel- Moore and Bulik (2007) recently summarized, “The single best predictor of risk for developing an eating disorder is be- ing female . . .” (p. 182).

• The prevalence of eating disorders has risen, as the image of the ideal woman has increasingly emphasized extreme thin- ness (Hoek & van Hoeken, 2003; Wiseman et al., 1992).

Marilyn Monroe, the 1950s movie idol, was the iconic image of the curvy figure that defined beauty in that era.

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child sexual abuse more often than normal controls but not more often than women suffering from other psychological problems (Palmer, 1995; Welch & Fairburn, 1996). Sexual abuse increases the risk for a variety of psychological problems, including, but not limited to, eating disorders.

Finally, we should note that many parents struggle with diet and thinness themselves. They are models of preoccupation for their children. Other parents directly encourage their children to be extra thin as a part of the general push to compete with their peers (Field & Kitos, 2010; Vandereycken, 2002).

Psychological Factors Researchers have hypothesized about many psychological factors contributing to eating disorders. Here we highlight four of the most important: control issues, depression/dysphoria, body im- age dissatisfaction, and reactions to dietary restraint.

A STRuGGLE FOR PERFECTION AND CONTROL One of the first and most prolific clinical observers of eating disorders was Hilde Bruch (1904–1984), a physician who fled her native Ger- many in 1933 and studied psychiatry in the United States. Bruch viewed a struggle for control as the central psychological issue in the development of eating disorders (Bruch, 1982). Bruch ob- served that girls with eating disorders seem overly conforming and eager to please. She suggested that they give up too much of the normal adolescent struggle for autonomy. Bruch viewed obsessive efforts to control eating and weight as a way that these overly compliant “good girls” control themselves further. At the same time, Bruch also saw their dieting as an attempt to wrest at least a little control from their parents—control over what they eat. In this struggle for control, young people with anorexia ner- vosa (at least the restricting subtype) “succeed” and take pride in their extreme self-control.

Perfectionism is another part of the endless pursuit of control. Perfectionists set unrealistically high standards, are self- critical, and demand a nearly flawless performance from themselves. Young women with eating disorders endorse perfectionist goals both about eating and weight and about general expectations for themselves (Bastiani et al., 1995; Jacobi & Fittig, 2010).

Young people with eating disorders may also try to control their own emotions excessively (Bruch, 1982). They may lack interoceptive awareness—recognition of internal cues, including hunger and various emotional states. One large study found that lack of interoceptive awareness predicted the development of eat- ing disorders two years in the future (Leon et al., 1993, 1995). People with eating disorders appear to be more tuned in to how they look than how they feel—sad, angry, happy, or hungry (Viken et al., 2002).

DEPRESSION, LOW SELF-ESTEEM, AND DySPhORIA Depression is often comorbid with eating disorders, particularly bulimia nervosa (Halmi, 2010). Antidepressant medications

considerable conflict and rejection in their families, difficulties that also may contribute to their depression. In contrast, young people with anorexia generally perceive their families as cohesive and nonconflictual (Fornari et al., 1999; Vandereycken, 1995).

Although the families of young people with anorexia ner- vosa appear to be well functioning, some theorists see them as being too close—as enmeshed families, families whose members are overly involved in one another’s lives. According to the en- meshment hypothesis, young people with anorexia nervosa are obsessed with controlling their eating, because eating is the only thing they can control in their intrusive families (Minuchin, Ros- man, Baker, , 1978). However, intrusive parental concern is prob- ably an effect, not a cause, of anorexia. Parents of an anorexic adolescent may well become “enmeshed” as a worried reaction to their daughter’s emaciation.

Child sexual abuse also is a risk factor for eating disorders (Jacobi & Fittig, 2010). However, sexual abuse may not pose a specific risk. Women with eating disorders report experiencing

Twiggy became a popular fashion model in the 1960s. Beginning her ca- reer at the age of 16, Twiggy’s stick figure helped to usher in the “culture of thinness.”

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Consistent with the dietary restraint hypothesis, adolescent girls who try to lose weight by fasting for 24 hours or more en- gage in more binge eating and develop bulimia more often five years later (Stice et al., 2008). Similarly, weight suppression— defined as highest adult weight minus current weight–predicts the maintenance and onset of bulimia 10 years later (Keel & Heatherton, 2010). An overly restrictive diet increases hunger, frustration, and lack of attention to internal cues, all of which make binge eating more likely. And “quick fix” diets rarely work, leaving dieters with a sense of failure, disappointment, and self- criticism, negative emotions that lower self-esteem and lead to more binge eating.

Dietary restraint also may directly cause some of the symptoms of anorexia nervosa. The military studies of semi- starvation conducted during World War II found that, dur- ing refeeding, many men felt intense, uncontrollable hunger, even after eating a considerable amount of food (Keys et al., 1950). Perhaps a similar reaction explains some of the intense fear of losing control and gaining weight found in anorexia nervosa.

While extreme restriction and quick-fix diets are unhealthy, sensible dieting is not. Normal weight women randomly assigned to a low-calorie diet lose weight and decrease binge eating 18 weeks later in comparison to women assigned to no diet (Presnell & Stice, 2003). As with so many things, finding a balanced middle ground is the key.

reduce some symptoms of bulimia nervosa, suggesting that, in some cases, bulimia is a reaction to depression (Mitchell, Ray- mond, & Specker, 1993). In other cases, depression may instead be a reaction to an eating disorder (Polivy & Herman, 2002). Depression improves markedly following successful group psy- chotherapy for bulimia (Mitchell et al., 1990). And a study of anorexia nervosa found considerable depression at the time of the original diagnosis but not at a six-year follow-up (Rastam, Gillberg, & Gillberg, 1995).

Depressive symptoms, and not necessarily clinical depres- sion, also may play a role in eating disorders. Low self-esteem is a particular concern (Fairburn et al., 1997). In particular, women with eating disorders may be preoccupied with their social self, how they present themselves in public and how other people perceive and evaluate them (Striegel-Moore, Silberstein, & Rodin, 1993). Women with bulimia nervosa or a negative body image report more public self-consciousness, social anxiety, and perceived fraudulence (Striegel-Moore et al., 1993). They also show increases in self-criticism and deterioration in mood fol- lowing negative social interactions (Vögele & Gibson, 2010). In short, people with eating disorders often depend on others for self-esteem.

Depressive symptoms also can play a role in maintaining problematic eating behaviors. Dysphoria or negative mood states commonly trigger episodes of binge eating (Vögele & Gibson, 2010). The dysphoria may be brought on by social criticism or conflict, dissatisfaction with eating and diet, or an ongoing de- pressive episode. In summary, clinical depression can either be a cause or a reaction to eating disorders, while depressed moods, low self-esteem, and dysphoria may contribute to the onset or maintenance of symptoms.

Negative Body image A negative body image, a highly critical evaluation of one’s weight and shape, is widely thought to contribute to the development of eating disorders (Polivy & Herman, 2002). One way to assess a negative body image is to compare people’s ratings of their current and ideal size by ask- ing them to pick from the schematics in Figure 10.4. Several longitudinal studies have found negative evaluations of weight, shape, and appearance to predict the subsequent development of disordered eating (Jacobi & Fittig, 2010). A negative body image may be a particular problem when combined with other risk factors, including perfectionism and low self-esteem (Field & Kitos, 2010).

dietary restraiNt Some symptoms of eating disorders may be effects of dietary restraint, that is, direct consequences of overly restrictive eating (Heatherton & Polivy, 1992). Ironically, many of the “out-of-control” symptoms of eating disorders are caused by inappropriate efforts to “control” eating. These symptoms in- clude binge eating, preoccupation with food, and perhaps out-of- control feelings of hunger.

figure 10.4 These figures are often used as one way to assess body image. People pick figures representing their current and ideal shape. The discrepancy between the ratings is a measure of negative body image. Source: From p. 79 in “Assessing Body Image Disturbance: Measures, Methodology, and Implementation” by J. Kevin Thompson, in Body Image, Eating Disorders and Obesity, Ed. by J. K. Thompson. American Psychological Association, Washington, DC, Copyright © 1996.

1 2 3 4 5 6 7 8 9

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of disordered eating in the only adoption study completed to date (Klump et al., 2009).

Genetic contributions to eating disorders could be explained by several different mechanisms. Eating disorders are unlikely to be directly inherited. Rather, genes may influence personality characteristics such as anxiety that, in turn, increase the risk for an eating disorder (Klump & Culbert, 2007). Or a certain body type may be inherited. Genetics contribute substantially to BMI (Wade, 2010). Inheriting a thin body type may increase the risk for anorexia—when combined with the culture of thinness, inter- nalization of the standard, and perfectionism. Similarly, a more rounded body type may increase the risk for bulimia—when combined with social pressures to maintain a weight below one’s natural set point.

Consistent with these hypotheses, recent evidence shows that genes influence eating pathology after puberty but not be- fore (Culbert et al., 2009). Genetic influences also are stronger among women who engage in dietary restraint (Racine et al., 2011). Genes clearly affect weight and body type, but we can- not mindlessly conclude that eating disorders are genetic without carefully considering genetic mechanisms and gene-environment interactions.

In extremely rare cases, eating disorders have been linked with a specific biological abnormality, such as a hormonal distur- bance or a lesion in the hypothalamus, the area of the brain that regulates routine biological functions, including appetite. But in most cases, the problem appears to be the result of an interaction of biological, psychological, and social risk factors.

Integration and Alternative Pathways Social and cultural values that emphasize thinness, beauty, and ap- pearance over agency are the starting point in understanding eat- ing disorders, particularly among young women. Risk factors that combine with cultural attitudes to produce eating disorders include direct familial and social pressures to be thin, a negative body im- age, dietary restraint, and genetic influences on body weight and shape (Jacobi et al., 2004; Stice, 2001, 2002). Less obvious risk fac- tors include preoccupation with external evaluation, lack of intero- ceptive awareness, and excessive conformity and self-control.

The etiology of eating disorders underscores the importance of equifinality—there are many pathways to developing an eat- ing disorder (Halmi, 1997). Some women are naturally thin, but their perfectionism drives them to become even thinner. Other women may have a more rounded body type determined by ge- netics, and they struggle, and repeatedly fail, to mold their body into something it was never meant to be. For some people, an eating disorder is an expression of depression. Others may de- velop an eating disorder because they focus on outward appear- ances instead of internal values. Finding the middle ground of a healthy weight can be very difficult, particularly when the cul- ture of thinness sets unrealistic standards of beauty, especially for young women.

Biological Factors Our bodies, in fact, seek a middle ground. Physiologically, weight is maintained around weight set points, fixed weights or small ranges of weight. Weight regulation around set points results from the interplay between behavior (e.g., exercise, eating), peripheral physiological activity (e.g., digestion, metabolism), and central physiological activity (e.g., neurotransmitter release; Blundell, 1995). The process is very much like the way a thermostat regulates heating and cooling to maintain air temperature at a given setting. Thus, if weight declines, hunger increases and food consumption goes up (Keesey, 1995). There is a slowing of the metabolic rate, the rate at which the body expends energy, and movement toward hyperlipogenesis, the storage of abnormally large amounts of fat in fat cells throughout the body (Brownell & Fairburn, 1995). All these reactions have obvious survival value and are likely products of evolution. The body does not distinguish between intentional attempts to lose weight and potential starvation.

Genetic factors also contribute to eating disorders. An early twin study of bulimia nervosa found a concordance rate of 23 percent for MZ twins and 9 percent for DZ twins (Kendler et al., 1991). Higher MZ than DZ concordance rates for anorexia nervosa (Bulik et al., 2006) and for dysfunctional eating attitudes have also been reported (Klump, McGue, & Iacono, 2000). Ge- netic factors also contributed substantially to various symptoms

Beyonce is a gorgeous example of a bigger but ideal body type.

278 CHAPTER 10 feeding and eating disorders

tried, but accumulating evidence indicates that family therapy is more effective than individual treatment, especially for children and adolescents (Lock et al., 2010; Le Grange & Hoste, 2010). The most carefully studied family therapy is the Maudsley method (named after Maudsley Hospital in London where the treatment was developed). In the Maudsley method, parents take complete control over the anorexic child’s eating, planning meals, preparing food, and monitoring eating. Parents do not blame the adolescent for her problems, but emphasize the uncontrollable nature of an- orexia and the importance of taking her “medicine”—food—in order to get better. Age-appropriate autonomy is returned to the teenager as eating and weight improve (Lock et al., 2010; Loeb et al., 2007). Growing evidence supports the effectiveness of the Maudsley method in treating anorexia and perhaps bulimia too (Le Grange & Hoste, 2010).

Many individual therapies also have been tried, including (1) Bruch’s (1982) modified psychodynamic therapy designed to increase interoceptive awareness and correct distorted per- ceptions of self; (2) feminist therapies, which encourage young women to pursue their own values rather than blindly adopt- ing prescribed social roles (Fallon, Katzman, & Wooley, 1994); and (3) various cognitive behavioral approaches. Un- fortunately, little evidence supports the effectiveness of any individual treatment (Wilson, 2010). Even worse, medication (antidepressants often are prescribed) and nutritional coun- seling not only offer little benefit, but patients also routinely drop out of these treatments (McElroy et al., 2010; Walsh et al., 2006; Wilson, Grilo, & Vitousek, 2007). Clearly, finding effective treatments for anorexia nervosa should be a research and public health priority.

Course and Outcome of Anorexia Nervosa Evidence on the course and outcome of anorexia nervosa further shows the limited effectiveness of contemporary treatments. At 10- to 20-year follow-up, nearly half of patients have a weight within the normal range, 20 percent remain significantly below their healthy body weight, and the remainder are intermediate in weight (Steinhausen, 2002). Perhaps 5 percent of patients starve themselves to death or die of related complications, including suicide.

Although important, weight gain is not the only measure of the course of anorexia nervosa. In fact, more than half the women with a history of anorexia nervosa continue to be preoc- cupied with diet, weight, and body shape, notwithstanding gains in weight. Moreover, people may also develop new problems with social life, depression, or bulimia, as a result of their perfec- tionism, reliance on external evaluation, or continued struggles with body image (Keel, 2010). Predictors of a better prognosis include an early age of onset, conflict-free parent–child relation- ships, early treatment, less weight loss, and the absence of binge eating and purging (Steinhausen, 2002). The following account, written by a young woman after her long and, finally, successful

Treatment of Anorexia The treatments for anorexia nervosa and bulimia nervosa dif- fer in approach and effectiveness; therefore, we consider them separately. The treatment of anorexia nervosa usually focuses on two goals. The first is to help the patient gain at least a mini- mal amount of weight. If weight loss is severe, the patient may be treated in an inpatient setting. Hospitalized patients may receive forced or intravenous feeding, or participate in strict behavior therapy programs that make rewards contingent on weight gain. Hospitalization also may be needed to prevent suicide, to address severe depression or medical complications, or to remove the patient temporarily from a dysfunctional social circumstance (Garner & Needleman, 1996).

The second goal in treating anorexia nervosa is to address the broader eating difficulties. Many different treatments have been

Brazilian model Ana Carolina Reston died in 2006 as a result of complications due to anorexia nervosa. Bans on super-thin models have been considered in order to protect both the models and their fans.

feeding and eating disorders CHAPTER 10 279

& Fairburn, 1998), although individual therapy is more effective (Thompson-Brenner, Glass, & Westen, 2003).

Interpersonal Psychotherapy Interpersonal psychotherapy also can be an effective treatment for bulimia nervosa. This is surprising because interpersonal therapy does not address eating disorders directly but instead focuses on difficulties in close relationships. In fact, interper- sonal therapy for bulimia initially was studied as a placebo treat- ment. Fairburn and colleagues (1991, 1993) wanted to evaluate whether cognitive behavior therapy had specific effects beyond the general benefits of psychotherapy. They chose interpersonal therapy as a credible placebo, because interpersonal problems of- ten are associated with bulimia nervosa. But they hypothesized that cognitive behavior therapy would outperform the interper- sonal approach.

When Fairburn and colleagues (1991) evaluated outcomes shortly after treatment, they found that cognitive behavior ther- apy was more effective than interpersonal therapy in changing dieting behavior, self-induced vomiting, and attitudes about weight and shape. Cognitive behavior therapy also was more effective than a third condition, behavior therapy alone, in terms of attitude change. However, the results of the two behavioral treatments were similar in other respects.

A very different picture emerged at 12-month follow-up. The behavior therapy group alone deteriorated over time, and a large number of patients dropped out. The cognitive behavior therapy group maintained fairly stable improvements. But the in- terpersonal therapy group continued to improve. At one-year fol- low-up, in fact, interpersonal therapy equaled cognitive behavior therapy and outdistanced the behavior therapy alone (Fairburn et al., 1993).

The continued improvement for interpersonal therapy was surprising and impressive, for at least two reasons. First, the in- terpersonal treatments explicitly excluded direct discussions of eating, diet, and related topics. Second, the investigators had lower expectations for interpersonal therapy, and the allegiance effect often influences treatment outcome (see Research Methods on p. xxx). A larger study replicated these results, although cogni- tive behavior therapy again produced more rapid change (Agras et al., 2000).

Antidepressant Medications All classes of antidepressant medications are somewhat effective in treating bulimia nervosa; however, medication alone is not the treatment of choice. Binge eating and compensatory behavior improve only among a minority of people treated with antide- pressants, and relapse is common when medication is stopped (McElroy et al., 2010). Most importantly, research shows that cognitive behavior therapy is more effective (Hay & Claudino, 2010; Walsh et al., 1997; Wilson et al., 1999). One exception may be treating bulimia in a primary care setting, where most

struggle with anorexia nervosa, illustrates some of the continuing problems:

I do not have a story that ends with a miraculous recovery, and I would be suspicious of anyone who claimed that they had completely gotten over an eating disorder. I continue to strug- gle with worries about food and my body. I exercise every day without fail. I am prone to stress fractures and will most likely encounter early osteoporosis due to the irreversible effects of starvation on my bones. I am lucky that I will be able to have children someday, though many long-term anorexics are never able to. Despite these lingering effects of the disorder, they pale in comparison to what I consider to be the most detrimental of all. When I look back on those six or so years, it sickens me to realize how much of life I missed. I allowed my obsession with my weight to take over my life (Zorn, 1998, p. 21).

Treatment of Bulimia Researchers have developed several approaches to treating bu- limia nervosa. The most effective include cognitive behav- ior therapy, interpersonal psychotherapy, and antidepressant medication.

Cognitive Behavior Therapy The most thoroughly researched psychotherapy for bulimia ner- vosa is cognitive behavior therapy (Wilson, Grilo, & Vitousek, 2007). As developed by the British psychiatrist Christopher Fair- burn, the cognitive behavioral approach views bulimia as stem- ming from several maladaptive tendencies, including an excessive emphasis on weight and shape; perfectionism; and dichotomous “black or white” thinking (Fairburn, 1996). Fairburn’s cognitive behavioral treatment includes three stages. First, the therapist uses education and behavioral strategies to normalize eating pat- terns. The goal is to end the cycle where extreme dietary restraint leads to binge eating and, in turn, to purging. Second, the thera- pist addresses the client’s broader, dysfunctional beliefs about self, appearance, and dieting. Techniques include a variation of Beck’s cognitive therapy to address perfectionism or depression. Indi- vidual problems such as poor impulse control or troubled rela- tionships also may be addressed at this stage. Third, the therapist attempts to consolidate gains and prepare the client for expected relapses in the future. Key goals at this final stage of treatment are to develop realistic expectations about eating, weight concerns, and binge eating, as well as clear strategies for coping with re- lapses in advance (Fairburn, 2002).

Overall, cognitive behavior therapy leads to a 70 percent to 80 percent reduction in binge eating and purging. Between one- third and one-half of all clients are able to cease the bulimic pat- tern completely, and the majority of individuals maintain these gains at six-month to one-year follow-up (Agras et al., 2000; Fair- burn et al., 1993). Cognitive behavior therapy also may be effec- tive in group (Mitchell et al., 1990) and self-help formats (Carter

280 CHAPTER 10 feeding and eating disorders

improve with improvements in bulimia nervosa (Keel & Mitchell, 1997). Predictors of continued binge eating include a longer du- ration, greater emphasis on shape and weight, childhood obesity, poorer social adjustment, persistent compensatory behavior, and comorbid alcohol abuse (Fairburn et al., 2003; Keel, 2010).

Prevention of Eating Disorders Can eating disorders be prevented? This question is of huge im- portance, especially given the pervasive body dissatisfaction and disordered eating found among women today. Until recently, the results of prevention research were discouraging. Few, if any, benefits were produced by first-generation prevention efforts, which focused on education about the adverse effects of eat- ing disorders, or by second-generation initiatives offering edu- cation about resisting the culture of thinness. However, a third

patients fail to complete self-help cognitive behavior therapy pro- grams but are more likely to follow through with antidepressant medication (Walsh et al., 2004). Overall, cognitive behavior ther- apy is the first-line treatment for bulimia, antidepressant medica- tion may be a useful supplement, and interpersonal therapy is a slower acting alternative (Wilson, 2010).

Course and Outcome of Bulimia Nervosa Bulimia nervosa has a more favorable course than anorexia ner- vosa, especially with treatment (Thomson-Brenner et al., 2003). About five years following diagnosis, 70 percent of patients are free of symptoms, 20 percent show improvement but continue to struggle, and one in 10 are chronically ill (Keel, 2010). In contrast to anorexia, mortality has been thought to be rare for bulimia, but a recent study found elevated rates, particularly for suicide (Crow et al., 2009). Comorbid psychological disorders also tend to

rESEarCh methods

Psychotherapy Placebos

A placebo is a treatment that contains no active ingredi-ents for the disorder being treated. A placebo control group receives only a placebo treatment. Scientists must include placebo control groups in treatment outcome research, because the mere expectation of change can produce benefits. New treatments work, in part, because the client and the thera- pist expect them to work.

Medication placebos are easily administered. Physicians give patients a pill that looks like the real medication but contains no active chemical ingredients. Psychotherapy placebos are much more challenging. How can we create a psychological treatment that contains no active ingredients but increases the client’s ex- pectations for change just as much as the real treatment?

One approach is to offer an established, alternative therapy, but one not designed to treat the disorder being studied. In their study of bulimia nervosa, Fairburn et al. (1993) thought interper- sonal therapy was a good placebo. The investigators believed that interpersonal therapy contained no “active ingredients” for treating bulimia nervosa, but thought clients would view it as legitimate.

But getting clients to believe does not fully resolve the psy- chotherapy placebo problem. Researchers “believe” in their treatment too—otherwise they would not be studying it. The allegiance effect shows us that a therapist’s beliefs also help to make treatment work. The allegiance effect tells us that cogni- tive behavior therapy should have been more successful in the Fairburn and colleagues (1993) study, for example, because the investigators were cognitive behavior therapists. In fact, we are

particularly impressed by the results for interpersonal therapy, because it overcame the allegiance effect.

What research method controls for the experimenter’s expecta- tions? In drug research, scientists use the double-blind study, where neither the patient nor the therapist knows whether the patient is receiving an active treatment or a placebo. But even double-blind studies are not always easy to interpret. Medica- tions are more effective when they produce more side effects (Greenberg et al., 1994). Side effects may increase the patient’s expectations for change, because the drug seems powerful. Or side effects may allow clinicians to determine whether patients are receiving the real medication.

In any case, “real” and placebo psychotherapies are transpar- ent to therapists, making it impossible to conduct double-blind studies of psychotherapy. Another way of addressing the al- legiance effect in psychotherapy outcome research is to have investigators who hold opposing allegiances participate in the same study. Cognitive behavior therapy is offered by cognitive behavior therapists, interpersonal therapists deliver interper- sonal therapy, and so on. This overcomes the allegiance effect but creates a new problem: Because the same therapists cannot deliver the different treatments, effects due to the individual therapists are uncontrolled.

Two conclusions seem clear. First, we must recognize that the expectations of clients, therapists, and experimenters can influ- ence the findings of therapy outcome research. Second, we are particularly impressed when, contrary to expectations, a placebo psychotherapy is as effective as the “real thing.”

feeding and eating disorders CHAPTER 10 281

conditions led to improvements in body dissatisfaction, internal- ization of the thin ideal, dieting, and binge eating/purging (Stice et al., 2006). Figure 10.5 shows the results for binge eating.

The results for the dissonance intervention have been replicated in a “real-world” setting (Stice et al., 2009), and an Internet-based program also shows promising results (Stice et al., 2012). Moreover, peer-led dissonance groups in sororities also show positive effects (Becker et al., 2008). Psychologists and soci- ety clearly have a long way to go to help women, and men, find the right balance between eating too little and too much, being obsessed with appearance, and being lax about health. Still, pre- vention research is an encouraging step in the right direction.

generation of more subtle prevention efforts is promising (Stice & Shaw, 2004).

More successful prevention efforts attack the thinness ideal indirectly, or promote healthy eating rather than stopping unhealthy habits (Stice et al., 2006). For example, “dissonance interventions” ask participants to complete tasks inconsistent with the thinness ideal, for example, discussing how to help younger girls from becoming obsessed with their appearance. The healthy approach emphasizes the benefits of eating well and exercising. Of 481 adolescent girls randomly assigned to one of these three-hour programs versus an assessment-only or placebo (writing about emotional issues) control group, the prevention

The fashion industry is making occasional efforts to portray beautiful women in a more realistic form, as illustrated by these plus size Swedish mannequins.

Karlie Kloss. Even up-and-coming fashion models continue to be extremely thin.

figure 10.5 Binge eating 6 and 12 months after either dissonance, healthy weight, or control interventions. At both times, the healthy weight program produced significantly less binge eating than control conditions. Differences for dissonance training approached significance at 6 months. Source: Stice, Eric, Heather Shaw, Emily Burton and Emily Wade. Dissonance and healthy weight eating disorder prevention programs: A randomized efficacy trial. Journal of Consulting and Clinical Psychology. Apr 2006; 74(2): 263–275.

Assessment only

Expressive writing

Healthy weight

Dissonance

30%25%20%15%10%5%0%

28 26

28 26

15 13

23 17

6-month binge eating

1-year binge eating

282 CHAPTER 10 feeding and eating disorders

getting HelP

Eating disorders are very common, so it is likely that you or someone close to you may be struggling with eating issues. What can help? One step is to get more information, but you need to be care- ful. Some self-help books and websites on eating disorders offer misleading information. And please beware of “pro-ana” and “pro-mia” websites that actually encourage eating disor- ders. One website that we recommend is the homepage of the National Eating Disorders Awareness Association, a nonprofit organization dedicated to increasing awareness and prevention of eating disorders. The Web page of the National Institute of Mental Health also contains helpful information about eating disorders. An excellent self-help book is Overcoming Binge Eating, by Christopher Fairburn, whose treatment research is discussed in this chapter. Wasted by Marya Hornbacher is a no- nonsense memoir about struggles with anorexia and bulimia. For parents, we recommend Help Your Teenager Beat an Eating Disorder by James Lock and Daniel Le Grange, whose promising family therapy techniques are also discussed in this chapter.

If you are seriously concerned about your own eating, weight, or body shape, you should talk with a professional. Colleges and

universities often have special resources for eating disorders. Call your student health service for information. Another option is to talk with your family physician. You should have a physi- cal exam to explore possible medical complications, and your physician also should know of mental health professionals who specialize in eating disorders. As indicated by the research we review in this chapter, some of treatments you should consider are cognitive behavior therapy, the most strongly supported treatment; interpersonal therapy; family therapy; and antide- pressant medication. Hospitalization may be another option, but only for very severe weight loss.

If you are concerned about a friend’s eating, you should make a plan and talk to her or him. Bring some information on local re- sources for treating eating disorders. And be prepared to listen as well as to talk! Your friend probably has not confided about her problems with many people. If your friend denies a problem, there is no point in arguing. You have done your job by raising the issue. It will be up to her to admit to the problem and get help. A good resource before and after talking with a friend is Surviving an Eating Disorder: Strategies for Friends and Families, by Michele Siegel, Judith Brisman, and Margot Weinshel.

10 Summary The defining symptoms of anorexia nervosa include extreme emaciation, a disturbed perception of one’s body, and an intense fear of gaining weight.

The defining symptoms of bulimia nervosa are binge eating and compensatory behavior (purging or excessive exercise), and undue focus on weight and shape.

Binge-eating disorder is included in the DSM-5, but obesity is not.

The prevalence of both anorexia nervosa and bulimia nervosa has increased dramatically in recent decades, particularly among young women.

Our society’s gender roles, standards of beauty, and pubertal changes in body shape and weight all contribute to the onset of eating disorders in young women.

Four psychological factors in the development of eating disor- ders are issues of control and perfectionism, dysphoria com- bined with a lack of interoceptive awareness, body image dissat- isfaction, and reactions to dietary restraint.

Biological contributions to eating disorders include the body’s attempts to maintain weight set points and genetic influences on body weight and shape.

There is no clearly effective treatment for anorexia nervosa, which may require inpatient treatment, although a new form of family therapy shows promise among adolescents.

Cognitive behavior therapy is an effective first line treat- ment for bulimia, while interpersonal psychotherapy and antidepressant medication also can be effective secondary treatments.

Anorexia and to a lesser extent, bulimia, can be chronic, with a continuation of eating dysfunction even when some symptoms improve.

Recent research provides hope for the prevention of dis- ordered eating, especially efforts focused on maintaining healthy weight or creating dissonance about the culture of thinness.

feeding and eating disorders CHAPTER 10 283

10.1 How can you tell if someone has an eating disorder? The most obvious and most dangerous symptom of anorexia nervosa is a significantly low weight. . . (see page 265).

10.2 How do images of women in the media contribute to eating disorders? Popular attitudes about women in the United States tell us that “looks are everything,” and thinness is essential to good looks . . . (see page 272).

10.3 Do men suffer from eating disorders? . . . some experts argue that pressures to be strong and muscular have created a new eating disorder among males . . . (see page 264).

10.4 What is binge-eating disorder? Binge-eating disorder, episodes of binge eating without compensa- tory behavior, is a new diagnosis in DSM-5. (see page 269).

10.5 Why do some girls and women develop eating disorders when others do not? . . . not every woman in the United States develops an eating disorder, so other factors must interact with culture to produce eating disorders . . . (see page 274).

10.6 What treatments work for anorexia and bulimia? The treatments for anorexia nervosa and bulimia nervosa differ in approach and effectiveness . . . (see page 278).

10.7 Can eating disorders be prevented? This question is of huge importance, especially given the pervasive body dissatisfaction and disordered eating found among women to- day . . . (see page 280).

critical thinking review

The Big Picture

key terms anorexia nervosa 263 binge eating 268 binge-eating disorder 269

body image 276 bulimia nervosa 263 cohort 271

cohort effects 271 obesity 269

purging 268 weight set points 277

Virtual Case Studies

Virtual Case Studies offers you a science-based, interactive simulation where you can learn how a number of risk factors and protective factors could impact disorder development in a virtual person. As you progress through the simulation you will not act as the character or as a clinician, but will be able to independently explore a variety of different behaviors, events, and outcomes that one who suffers from a disorder could potentially encounter. You can access the Virtual Case Study on Eating Disorders at mypsychlab.com.

FPO

11

substance-related and addictive disorders

substance-related and addictive disorders CHAPTER 11 285

11 The Big Picture learning objectives

11.1 What evidence is needed to show that a drug is addictive?

11.2 What are the long-term consequences of

abusing psychomotor stimulants?

11.3 Where is the boundary between substance use

disorders and recreational drug use?

11.4 In what ways are drug problems different among the elderly?

11.5 What are the most important risk factors for alcoholism?

11.6 How does AA differ from other approaches

to treating alcoholism?

11.7 What factors predict better long-term outcome for treatment of alcoholism?

The abuse of alcohol and other drugs is one of the most serious prob- lems facing our society today. It is likely that you or someone close to you will be affected by the substance use issues outlined in this chap- ter. Alcohol and drug problems receive a great deal of attention in the popular media, as illustrated by actress Lindsay Lohan’s repeated struggles with alcohol and the drug-related suicide of Kurt Cobain, leader of the rock group Nirvana. Research efforts, treatment priori- ties, and national publicity have all helped transform national atti- tudes about the abuse of chemical substances. The picture of the drug addict as a homeless derelict whose personality defects and lack of motivation are largely responsible for the problem has been replaced by a new view in which substance use disorders are seen as chronic mental disorders that affect people from all walks of life.

Overview The costs associated with substance use disorders are astronomi- cal. According to the World Health Organization, alcohol use was responsible for 5 percent of the total burden of disease and

disability worldwide in 2004 (Rehm et al., 2009). Cirrhosis of the liver, which is frequently the result of chronic alcoholism, is a leading cause of death in the United States. In addition, alco- hol plays a prominent role in many suicides, homicides, and mo- tor vehicle accidents. The rate of deaths attributable to the use of tobacco is growing rapidly, particularly in developing countries, where 50 percent of adult men are regular smokers. By the year 2020, tobacco is expected to kill between 8 million and 9 million people annually worldwide, more than any single disease, includ- ing AIDS (Lopez et al., 2006).

DSM-5 defines substance use disorders in terms of a mal- adaptive pattern of behaviors that are related to the continued use of drugs, in spite of the fact that their use creates a set of signifi- cant problems for the person. These include inability to control use of the drug, risky use of the drug, social impairment follow- ing repeated use, and pharmacological consequences. The latter include tolerance (the need for increased amounts of the drug to achieve intoxication) and withdrawal (unpleasant physical and psychological effects that the person experiences when he or she tries to stop taking the drug).

Some other terms have also been used to describe substance use disorders. In previous versions of the diagnostic manual, sub- stance dependence was a term that described substance use dis- orders that were at least moderate in severity (e.g., those with pharmacological consequences). Addiction is another term that is often used to describe problems such as alcoholism. Throughout this chapter, we will use the terms dependent and addiction to refer to relatively severe substance use problems.

The term addiction is being used more frequently in recent years, partly because the field has become increasingly interested in similarities and distinctions between substance use disorders and other kinds of impulsive behavior problems that involve loss of control or craving in one form or another. These include addiction-like problems such as pathological gambling, excessive use of the Internet, and hypersexual behavior (see the section on Impulse Control Disorders in Chapter 9 on page 252).

Drugs that are taken in excess, sometimes called psychoac- tive substances, are chemicals that alter a person’s mood, level of perception, or brain functioning (Schuckit, 2010). All drugs of abuse can be used to increase a person’s psychological comfort level (make one feel “high”) or to alter levels of consciousness. The list of chemicals on which people can become dependent is long and seems to be growing longer. It includes drugs that are legally available, whether over the counter or by prescription only, as well as many that are illegal.

Depressants of the central nervous system (CNS) include al- cohol as well as types of medications that are used to help people sleep, called hypnotics, and those for relieving anxiety, known as sedatives or anxiolytics. The CNS stimulants include illegal drugs like amphetamine and cocaine, as well as nicotine and caffeine. The opiates, also called narcotic analgesics, can be used clinically to decrease pain. The cannabinoids, such as marijuana, produce euphoria and an altered sense of time. At higher doses, they may

286 CHAPTER 11 substance-related and addictive disorders

produce hallucinations. People with a substance use disorder fre- quently abuse several types of drugs; this condition is known as polysubstance abuse.

One basic question we must address is whether we should view each type of addiction as a unique problem. Experts who answer “yes” to this question point out that each class of abused substance seems to affect the body in distinct ways. For example, when taken orally, some opiates can be used for long periods of time without leading to significant organ damage (Jaffe & Jaffe, 1999). Chronic use of alcohol and tobacco, on the other hand, can have a devastating impact on a person’s physical health.

Despite these differences, the various forms of substance use disorder share many common elements. All represent an inherent conflict between immediate pleasure and longer-term harmful consequences. The psychological and biochemical effects on the user are often similar, as are the negative consequences for both social and occupational behaviors. The reasons for initial experi- mentation with a drug, the factors that influence the transition to addiction, and the processes that lead to relapse after initial ef- forts to change are all similar in many respects. For these reasons, many clinicians and researchers have adopted a view of substance use disorders that emphasizes common causes, behaviors, and consequences (Lesch et al., 2011). In fact, DSM-5 employs a set of diagnostic criteria for substance use disorder that is relatively consistent for all drugs.

The variety of problems associated with substance use disor- ders can be illustrated using a case study of alcohol use disorder. Ernest Hemingway (1899–1961), a Nobel Prize–winning writer, was severely dependent on alcohol for many years. The following paragraphs, quoted from an article by Paul Johnson (1989), de- scribe the progression of Hemingway’s drinking and the problems that it created. They illustrate many typical features of substance use disorders, as well as the devastating impact that alcohol can have on various organs of the body. Johnson’s description also raises a number of interesting questions about the causes of this disorder. Most men and women consume alcoholic beverages at some point during their lives. Why do some people become de- pendent on alcohol while others do not? What factors influence the transition from social drinking to abuse?

Ernest Hemingway’s Alcohol Use Disorder Hemingway began to drink as a teenager, the local blacksmith se- cretly supplying him with strong cider. His mother noted his habit and always feared he would become an alcoholic. In Italy he pro- gressed to wine, then had his first hard liquor at the officers’ club in Milan. His wound [from World War I] and an unhappy love affair provoked heavy drinking: In the hospital, his wardrobe was found to be full of empty cognac bottles, an ominous sign. In Paris in the 1920s, he bought Beaune by the gallon at a wine coopera- tive and would and did drink five or six bottles of red at a meal. He taught Scott Fitzgerald to drink wine direct from the bottle, which, he said, was like “a girl going swimming without her swim- ming suit.” In New York, after signing his contract for The Sun

Also Rises, he was “cockeyed,” he said, for “several days,” prob- ably his first prolonged bout.

Hemingway particularly liked to drink with women, as this seemed to him, vicariously, to signify his mother’s approval. Had- ley [the first of his four wives] drank a lot with him, and wrote: “I still cherish, you know, the remark you made that you almost wor- shipped me as a drinker.” The same disastrous role was played by his pretty 1930s companion in Havana, Jane Mason, with whom he drank gin followed by champagne chasers and huge jars of iced daiquiris; it was indeed in Cuba in this decade that his drink- ing first got completely out of hand. One bartender there said he could “drink more martinis than any man I have ever seen.” On safari, he was seen sneaking out of his tent at 5 a.m. to get a drink. His brother Leicester said that, by the end of the 1930s, at Key West, he was drinking 17 scotch-and-sodas a day and often taking a bottle of champagne to bed with him at night.

At this period, his liver for the first time began to cause him acute pain. He was told by his doctor to give up alcohol com- pletely, and indeed he tried to limit his consumption to three whiskeys before dinner. But that did not last. During World War II his drinking mounted steadily and by the mid-1940s he was reportedly pouring gin into his tea at breakfast. A. E. Hotchner, interviewing him for Cosmopolitan in 1948, said he dispatched seven double-size Papa Doubles (the Havana drink named after him, a mixture of rum, grapefruit, and maraschino), and when he left for dinner took an eighth with him for the drive. And on top of all, there was constant whiskey: His son Patrick said his father got through a quart of whiskey a day for the last 20 years of his life.

Hemingway’s ability to hold his liquor was remarkable. Lillian Ross, who wrote his profile for the New Yorker, does not seem to have noticed he was drunk a lot of the time he talked to her. Denis Zaphior said of his last safari: “I suppose he was drunk the whole time but seldom showed it.” He also demonstrated an unusual ability to cut down his drinking or even to eliminate it altogether for brief periods, and this, in addition to his strong physique, en- abled him to survive.

But despite his physique, his alcoholism had a direct impact on his health, beginning with his damaged liver in the late 1930s. By 1959, following his last big drinking bout in Spain, he was ex- periencing both kidney and liver trouble and possibly hemochro- matosis (cirrhosis, bronzed skin, diabetes), edema of the ankles, cramps, chronic insomnia, blood-clotting and high blood uremia, as well as his skin complaints. He was impotent and prematurely aged. Even so, he was still on his feet, still alive; and the thought had become unbearable to him. His father had committed suicide because of his fear of mortal illness. Hemingway feared that his illnesses were not mortal: On July 2, 1961, after various unsuc- cessful treatments for depression and paranoia, he got hold of his best English double-barreled shotgun, put two canisters in it, and blew away his entire cranial vault.

Why did Hemingway long for death [and why did he drink]? He felt he was failing his art. Hemingway had many grievous

substance-related and addictive disorders CHAPTER 11 287

The number of problems that a person encounters seems to provide the most useful distinction between people who are ad- dicted to a substance and those who are not. These problems can be sorted loosely into two general areas: (1) patterns of patho- logical consumption, including impaired control over use of the drug and continued use in spite of mounting problems; and (2) consequences that follow a prolonged pattern of abuse, including social and occupational impairments, disruption of important interpersonal relationships, and deteriorating medical condition. Some of the physiological consequences may include the onset of tolerance and withdrawal.

It might seem that the actual amount of a drug of abuse that a person consumes would be the best indication of the existence of a problem. Hemingway, for example, clearly consumed enormous quantities of alcohol over a period of many years. The average person with an alcohol use disorder does drink more frequently and in larger quantities than the average person without an alco- hol use disorder (Keyes et al., 2009). Nevertheless, the amount of a drug that a specific person consumes is not a good way to de- fine substance use disorders, because people vary significantly in the amount of any given drug they can consume. Factors such as age, gender, activity level, and overall physical health influence a person’s ability to metabolize various kinds of drugs. For example, some people can drink a lot without developing problems; others drink relatively little and have difficulties.

Many psychological features or problems are associated with the problematic use of chemical substances. One such feature in- volves craving. This word is frequently used to describe a forceful urge to use drugs, but the relationship between craving and drug use is actually very complex (Eliason & Amodia, 2007; Sayette et al., 2000). People who are dependent on drugs often say that they take the drug to control how they are feeling. They need it to relieve negative mood states or to avoid withdrawal symptoms from previous episodes. They may feel compelled to take the drug as a way to prepare for certain activities, such as public speaking, writing, or sex. Some clinicians refer to this condition as psycho- logical dependence.

One useful index of craving is the amount of time that the person spends planning to take the drug. Is access to drugs or al- cohol a constant preoccupation? If the person is invited to a party or is planning to eat at a restaurant, does he or she always inquire about the availability of alcoholic drinks? If the person is going to spend a few days at the beach in a neighboring state, will he or she worry more about whether liquor stores will be closed on weekends or holidays than about having enough food, clothes, or recreational equipment?

As the problem progresses, it is not unusual for the person who abuses drugs to try to stop. In the case of alcoholism, for example, it is possible for even heavy drinkers to abstain for at least short periods of time. Most clinicians and researchers agree that diminished control over drinking is a crucial feature of the disorder. Some experts have described this issue as “freedom of choice.” When a person first experiments with the use of alcohol,

faults, but there was one thing he did not lack: artistic integrity. It shines like a beacon through his whole life. He set himself the task of creating a new way of writing English, and fiction, and he succeeded. It was one of the salient events in the history of our language and is now an inescapable part of it. He devoted to this task immense resources of creative skill, energy, and patience. That in itself was difficult. But far more difficult, as he discovered, was to maintain the high creative standards he had set himself. This became apparent to him in the mid-1930s and added to his habitual depression. From then on his few successful stories were aberrations in a long downward slide.

If Hemingway had been less of an artist, it might not have mattered to him as a man. He would simply have written and pub- lished inferior novels, as many writers do. But he knew when he wrote below his best, and the knowledge was intolerable to him. He sought the help of alcohol, even in working hours. He was first observed with a drink, a “Rum St. James,” in front of him while writing in the 1920s. This custom, rare at first, became intermit- tent, then invariable. By the 1940s, he was said to wake at 4:30 a.m. [He] “usually starts drinking right away and writes standing up, with a pencil in one hand and a drink in another.” The effect on his work was exactly as might be expected, disastrous. Heming- way began to produce large quantities of unpublishable material, or material he felt did not reach the minimum standard he set himself. Some was published nonetheless and was seen to be in- ferior, even a parody of his earlier work. There were one or two exceptions, notably The Old Man and the Sea (1952), which won him the Nobel Prize, though there was an element of self-par- ody in that, too. But the general level was low, and falling, and Hemingway’s awareness of his inability to recapture his genius, let alone develop it, accelerated the spinning circle of depression and drink (Johnson, 1989, pp. 58–59).

Symptoms Substance use disorders are associated with a host of problems, many of which are illustrated in the life of Ernest Hemingway. Nev- ertheless, they are difficult to define. Alcoholism is one important example. George Vaillant (1995), a psychiatrist at Harvard Medical School and the author of an important longitudinal study of alco- holic men, noted that it is difficult to say that one specific problem or set of problems represents the core features of this disorder:

Not only is there no single symptom that defines alcohol- ism, but often it is not who is drinking but who is watching that defines a symptom. A drinker may worry that he has an alcohol problem because of his impotence. His wife may drag him to an alcohol clinic because he slapped her during a blackout. Once he is at the clinic, the doctor calls him an alcoholic because of his abnormal liver-function tests. Later society labels him a drunk because of a second episode of driving while intoxicated. (p. 24)

288 CHAPTER 11 substance-related and addictive disorders

(see Chapter 14). This syndrome is called alcohol withdrawal delir- ium in DSM-5 if it is induced by withdrawal from alcohol.

The symptoms of withdrawal vary considerably for different kinds of substances. Unpleasant reactions are most evident during withdrawal from alcohol, opioids, and the general class of sedatives, hypnotics, and anxiolytics (such as Valium and Xanax). Withdrawal symptoms are also associated with stimulants, such as amphetamine, cocaine, and nicotine, although they are sometimes less pronounced than those associated with alcohol and opioids. Withdrawal symp- toms are not often seen after repeated use of hallucinogens, and they have not been demonstrated with phencyclidine (PCP). Caffeine is the most widely used psychoactive substance in the world. We all know people who crave coffee, especially in the morning. And some heavy coffee users experience severe headaches when they stop drinking caffeine (James & Keane, 2007).

All these problems serve to emphasize the fact that symptoms of substance use disorders fall along a continuum. It is convenient to consider these problems in terms of qualitative distinctions: people who can control their drinking and those who cannot; people who crave alcohol and those who do not; people who have developed a tolerance to the drug and those who have not; and so on. In fact, there are no clear dividing lines on any of these dimensions. Drug use disorders lie on a continuum of severity (Helzer et al., 2008). For this reason it is difficult to define the nature of substance use disorders.

People can become dependent on many different kinds of drugs. Although patterns of dependence are similar in some ways for all drugs, each type of drug also has some unique features. Table 11.1 provides a list of the different classes of drugs that are associated with the diagnosis of substance use disorders in DSM-5. This table provides a very brief overview of some of the similari- ties and differences among these drugs. We will return to this table later in this chapter, when we describe the DSM-5 approach to diagnosis of substance-related disorder.

In the next few pages, we briefly review some of the most important classes of drugs. For each group, we will describe short-term effects on physiology and behavior, as well as the con- sequences of long-term abuse. Unless otherwise specified, these

his or her behavior is clearly voluntary; the person is not com- pelled to drink. After drinking heavily for a long period of time, most people with a drinking disorder try to stop. Unfortunately, efforts at self-control are typically short-lived and usually fail.

Two particularly important features of substance use dis- orders are the phenomena known as tolerance and withdrawal. Tolerance refers to the process through which the nervous system becomes less sensitive to the effects of alcohol or any other drug of abuse. For example, a person who has been regularly exposed to alcohol will need to drink increased quantities to achieve the same subjective effect (“buzz,” “high,” or level of intoxication).

The development of drug tolerance seems to be the result of three separate mechanisms (Julien, Advokat, & Comaty, 2010). Two are pharmacological and the third is behavioral. Metabolic tolerance develops when repeated exposure to a drug causes the person’s liver to produce more enzymes that are used to metabo- lize, that is, break down, the drug. The drug, therefore, is me- tabolized more quickly and the person has to take increasingly larger doses in order to maintain the same level in his or her body. Pharmacodynamic tolerance occurs when receptors in the brain (see Figure 2.2 on page 34) adapt to continued presence of the drug. The neuron may adapt by reducing the number of recep- tors or by reducing their sensitivity to the drug. This process is known as down regulation. The third process involved in drug tol- erance involves behavioral conditioning mechanisms (Siegel, 2005). Cues that are regularly associated with the administration of a drug begin to function as conditioned stimuli and elicit a condi- tioned response that is opposite in direction to the natural effect of the drug. As this compensatory response increases in strength, it competes with the drug response so that larger amounts of the drug must be taken to achieve the same effect.

Some drugs are much more likely than others to produce a buildup of tolerance (APA, 2013). The most substantial tolerance effects are found among heavy users of opioids, such as heroin, and CNS stimulants, such as amphetamine and cocaine. Pro- nounced tolerance is also found among people who use alcohol and nicotine. The evidence is unclear regarding tolerance effects and prolonged use of marijuana and hashish. Most people who use cannabinoids are not aware of tolerance effects, but these ef- fects have been demonstrated in animal studies. Hallucinogens (LSD and PCP) may not lead to the development of tolerance.

Withdrawal refers to the symptoms experienced when a person stops using a drug. The symptoms can go on for several days. For example, alcohol is a CNS depressant, and the heavy drinker’s system becomes accustomed to functioning in a chroni- cally depressed state. When the person stops drinking, the system begins to rebound within several hours, producing many unpleas- ant side effects—hand tremors, sweating, nausea, anxiety, and insomnia. The most serious forms of withdrawal include convul- sions and visual, tactile, or auditory hallucinations. Some people develop delirium, a sudden disturbance of consciousness that is accompanied by changes in cognitive processes such as lack of awareness of the environment or inability to sustain attention

MyPsychLab Video Case

Alcoholism

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“The toughest thing I ever did was admitting that I had a problem.”

Watch the Video Chris: Alcohol Use Disorder

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How was Chris’s pattern of drinking different from that of his friends?

substance-related and addictive disorders CHAPTER 11 289

broken down or metabolized in the liver. The rate at which alcohol is metabolized varies from person to person, but the average person can metabolize about 1 ounce of 90-proof liquor or 12 ounces of beer per hour (Nathan, 1993). If the person’s consumption rate ex- ceeds this metabolic limit, then blood alcohol levels will rise.

Short-term effectS Blood alcohol levels are measured in terms of the amount of alcohol per unit of blood. A “drink” is con- sidered to be 12 ounces of beer, 4 ounces of wine, or 1 ounce of 86-proof whiskey. The average 160-pound man who consumes five drinks in one hour will have a blood alcohol level of 100 milli- grams (mg) per 100 milliliters (ml) of blood, or 100 mg percent (Kowalski, 1998). There is a strong correlation between blood alco- hol levels and CNS intoxicating effects. According to DSM-5, the symptoms of alcohol intoxication include slurred speech, lack of coordination, an unsteady gait, nystagmus (involuntary to-and-fro movement of the eyeballs induced when the person looks upward or to the side), impaired attention or memory, and stupor or coma.

In most states, the legal limit of alcohol concentration for driving is 80 mg percent because slowed reaction times and in- terference with other driving skills become particularly evident as blood alcohol levels exceed this level. People with levels of 150 to 300 mg percent will almost always act intoxicated. Neurologi- cal and respiration complications begin to appear at higher levels. There is an extreme risk of coma leading to toxic death when blood alcohol levels go above 400 mg percent.

Long-term conSequenceS The prolonged use and abuse of alcohol can have a devastating impact on many areas of a person’s life. The disruption of relationships with family and friends can be especially painful. The impact of Hemingway’s drinking on his writ- ing career and his family life is clearly evident. Most critics agree that

descriptions are based on information presented by William McKim (2006) in his textbook on drugs and behavior.

Alcohol Alcohol affects virtually every organ and system in the body. Af- ter alcohol has been ingested, it is absorbed through membranes in the stomach, small intestine, and colon. The rate at which it is absorbed is influenced by many variables, including the concen- tration of alcohol in the beverage (for example, distilled spirits are absorbed more rapidly than beer or wine), the volume and rate of consumption, and the presence of food in the digestive system. Af- ter it is absorbed, alcohol is distributed to all the body’s organ sys- tems. Almost all the alcohol that a person consumes is eventually

table 11.1 Comparison of Various Types of Substances and Possible Consequences of Their Use

Substance use Disorder

Intoxication

Withdrawal

Sleep Disorders

Sexual Dysfunction

Delirium

Dementia

Alcohol yes yes yes yes yes yes yes

Caffeine no yes yes yes no no no

Cannabis yes yes yes yes no yes no

Hallucinogens* yes yes no no no yes no

Inhalants yes yes no no no yes yes

Opioids yes yes yes yes yes yes no

Sedatives, hypnotics yes yes yes yes yes yes yes

Stimulants** yes yes yes yes yes yes no

Tobacco yes no yes yes no no no

Note: Columns 1–3 indicate whether DSM-5 provides a set of criteria for assigning a diagnosis of substance use disorder, intoxication, or withdrawal for each type of drug. Columns 4–7 indicate some (but not all) of the other forms of mental disorder that can be observed during either intoxication or withdrawal from persistent use of the drug. * includes phencyclidine and other hallucinogens ** includes amphetamines, cocaine, and other stimulants Source: Based on data from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

The negative consequences of alcohol use disorder typically include a devastating impact on social relationships and work performance.

290 CHAPTER 11 substance-related and addictive disorders

(Cornelius et al., 2008). The specific impact of alcohol varies among geographic regions, in part because of differences in the age structure of different populations. Deaths that result from alcohol-related injuries are much more common among young men, while deaths from alcohol-related diseases are responsible for more deaths among older men (Murray & Lopez, 1997; see Figure 11.1).

tobacco Nicotine is the active ingredient in tobacco, which is its only natural source. Nicotine is almost never taken in its pure form because it can be toxic. Very high doses have extremely unpleas- ant effects. Controlled doses are easier to achieve by smoking or chewing tobacco, which provides a diluted concentration of nicotine. Another way of ingesting nicotine is to inhale snuff (powdered tobacco) into the nostrils. When tobacco smoke is inhaled, nicotine is absorbed into the blood through the mu- cous membranes of the lungs. This route of administration results in the highest concentrations of nicotine because it is carried directly from the lungs to the heart and from there to the brain.

Short-term effectS The effects of nicotine on the pe- ripheral nervous system (see Chapter 2) include increases in heart rate and blood pressure. In the central nervous sys- tem, nicotine has pervasive effects on a number of neurotrans- mitter systems (Houezec, 1998). It stimulates the release of norepinephrine from several sites, producing CNS arousal. Nicotine also causes the release of dopamine and norepinephrine in the mesolimbic dopamine pathway, also known as the reward system of the brain. The serotonin system, which also mediates the effects of antidepressant medication, is influenced by nico- tine. In fact, some people have suggested that nicotine mimics the effects of antidepressant drugs.

Nicotine has a complex influence on subjective mood states. Many people say that they smoke because it makes them feel more relaxed. Some believe that it helps them control their subjective response to stress. This phenomenon is somewhat paradoxical in light of the fact that nicotine leads to increased arousal of the sympathetic nervous system. Various explana- tions may account for this apparent inconsistency. One involves

his literary accomplishments were confined primarily to the early stages of his career, before his alcoholism began to interfere with his ability to write. Drinking also took its toll on his marriages, which were characterized by frequent and occasionally furious conflict in public and by repeated episodes of verbal and physical abuse in pri- vate (Johnson, 1989). Also, the heavy use of alcohol by a pregnant woman can cause damage to her fetus (see Chapter 15).

Many people who abuse alcohol experience blackouts. In some cases, abusers may continue to function without passing out, but they will be unable to remember their behavior. An ex- ample is the person who drives home drunk from a party and in the morning finds a dent in the car bumper but can’t remember how it got there. Sometimes problem drinkers will be told by a friend about how they behaved at the previous night’s party, but they cannot remember what they did.

Regular heavy use of alcohol is also likely to interfere with job performance. Coworkers and supervisors may complain. At- tendance at work may become sporadic. Eventually, the heavy drinker may be suspended or fired. Related to job performance is the problem of financial difficulties. Losing one’s job is clearly detrimental to one’s financial stability, as are the costs of divorce, healthcare, liquor, and so on.

Many heavy drinkers encounter problems with legal authori- ties. These problems may include arrests for drunken driving and public intoxication, as well as charges of spouse and child abuse. Many forms of violent behavior are more likely to be committed when a person has been drinking.

On a biological level, prolonged exposure to high levels of alcohol can disrupt the functions of several important organ systems, especially the liver, pancreas, gastrointestinal system, cardiovascular system, and endocrine system. The symptoms of alcoholism include many secondary health problems, such as cir- rhosis of the liver, heart problems (in part, the result of being overweight), and various forms of cancer, as well as severe and persistent forms of neurocognitive disorder (see Chapter 14). Al- coholism is also associated with nutritional disturbances of many types, because chronic abusers often drink instead of eating bal- anced meals. In fact, over an extended period of time, alcohol de- pendence has more negative health consequences than does abuse of any other drug, with the exception of nicotine.

The misuse of alcohol leads to an enormous number of se- vere injuries and premature deaths in every region of the world

figure 11.1 male Deaths caused by Alcohol use in established market economies Young men are more likely to be killed by alcohol-related injuries, while older men often die as a result of alcohol-related disease. Source: Based on Murray and Lopez. 1997. Global Mortality, Disability, and the Contribution of Risk Factors: Global Burden of Disease Study. Lancet; 349.

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Short-term effectS Cocaine and amphetamines are called stimulants because they activate the sympathetic nervous system (Constable, 2004). They increase heart rate and blood pressure and dilate the blood vessels and the air passages of the lungs. Stimulants also suppress the appetite and prevent sleep. These effects have been among the reasons for the popularity and fre- quent abuse of stimulants. They have been used, for example, by truck drivers who want to stay awake on long trips and by stu- dents who want to stay awake to study for exams. Unfortunately, in addition to their addicting properties, large doses of amphet- amines can also lead to dizziness, confusion, and panic states, which clearly interfere with activities such as driving and studying.

Many people use (and abuse) stimulants because they induce a positive mood state. When they are injected, amphetamines and cocaine produce similar subjective effects, but the effects of cocaine do not last as long. Low doses of amphetamines make people feel more confident, friendly, and energetic. At higher doses, the person is likely to experience a brief, intense feeling of euphoria. The rushes associated with snorting or injecting co- caine are frequently described in sexual terms. Although many people believe that cocaine enhances sexual arousal and pleasure, most of the evidence suggests that prolonged use leads to sexual dysfunction (Jaffe, 1995). Tolerance develops quickly to the eu- phoric effects of stimulant drugs. The feelings of exhilaration and well-being are typically followed, several hours later, by the onset of lethargy and a mildly depressed or irritable mood.

Acute overdoses of stimulant drugs can result in irregular heartbeat, convulsions, coma, and death. The highly publicized overdose deaths of several prominent athletes, such as that of All- American basketball star Len Bias in 1986, indicate that the in- tense cardiovascular effects of cocaine can be fatal, even among people who are otherwise strong and healthy. Individual differ- ences in sensitivity to the subjective effects of cocaine may play a role in cocaine-related deaths. In other words, people who are re- sistant to cocaine-induced euphoria may consume unusually large quantities of the drug while trying to achieve the rush that others have described.

Long-term conSequenceS High doses of amphetamines and cocaine can lead to the onset of psychosis. The risk of a psy- chotic reaction seems to increase with repeated exposure to the drug (Bolla, Cadet, & London, 1998). This syndrome can ap- pear in people who have no prior history of mental disorder, and it usually disappears a few days after the drug has been cleared. Stimulants can also increase the severity of symptoms among people who had already developed some type of psychotic condi- tion. The symptoms of amphetamine psychosis include auditory and visual hallucinations, as well as delusions of persecution and grandeur.

As with other forms of addiction, the most devastating effects of stimulant drugs frequently center around the disruption of oc- cupational and social roles. The compulsion to continue taking cocaine can lead to physical exhaustion and financial ruin. People

differences in dosage levels; low doses of nicotine may lead to increased arousal while higher doses lead to relaxation. Another alternative involves withdrawal. Regular smokers may feel re- laxed when they smoke a cigarette because it relieves unpleasant symptoms of withdrawal.

Long-term conSequenceS Nicotine is one of the most harmful and deadly addictive drugs. Considerable evidence points to the development of both tolerance and withdrawal symptoms among people who regularly smoke or chew tobacco. The physiological symptoms of withdrawal from nicotine in- clude drowsiness, lightheadedness, headache, muscle tremors, and nausea. People who are attempting to quit smoking typically experience sleeping problems, weight gain, concentration diffi- culties, and mood swings ranging from anxiety to anger and de- pression (Hughes, 2007b). From a psychological point of view, withdrawal from nicotine is just as difficult as withdrawal from heroin. Many people report that these symptoms disappear after a few months, but some have serious cravings for several years after they quit.

People who smoke tobacco increase their risk of developing many fatal diseases, including heart disease, lung disease (bron- chitis and emphysema), and various types of cancer (Kozlowski, Henningfield, & Brigham, 2001). Eighty percent of all deaths caused by lung cancer can be attributed to smoking tobacco. More than 3.5 million people in the world die prematurely each year as a result of tobacco. Women who smoke are also more likely to experience fertility problems. Babies born to mothers who smoked during pregnancy are also likely to weigh less than those born to mothers who do not smoke, and they may be more vulnerable to certain types of birth defects.

Amphetamine and cocaine Members of the class of drugs known as psychomotor stimu- lants produce their effects by simulating the actions of certain neurotransmitters, specifically epinephrine, norepinephrine, dopamine, and serotonin (as discussed later in this chapter). Cocaine is a naturally occurring stimulant drug that is extracted from the leaf of a small tree that grows at high elevations, as in the Andes Mountains. The amphetamines (such as dexedrine and methamphetamine) are produced synthetically.

The stimulants can be taken orally, injected, or inhaled. It is easier to maintain a constant blood level when the drugs are taken orally. They are absorbed more slowly through the diges- tive system, and their effects are less potent. More dramatic ef- fects are achieved by injecting the drug or sniffing it. Cocaine can also be smoked, using various procedures that have been popularized in the past several years. Some people employ a par- ticularly dangerous procedure called “freebasing,” in which the drug is heated and its vapors are inhaled. Many people have been seriously burned when these highly combustible chemicals are accidentally ignited.

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The opiates can be taken orally, injected, or inhaled. Opium is sometimes eaten or smoked. When morphine is used as a pain- killer, it is taken orally so that it is absorbed slowly through the digestive system. People who use morphine for subjective effects most often inject the drug because it leads more quickly to high concentrations in brain tissue. Heroin can be injected, inhaled through the nose in the form of snuff, or smoked and inhaled through a pipe or tube.

Short-term effectS The opiates can induce a state of dreamlike euphoria, which may be accompanied by increased sensitivity in hearing and vision. People who inject morphine or heroin also experience a rush—a brief, intense feeling of pleasure that is sometimes described as being like an orgasm in the entire body.

Laboratory studies of mood indicate that the positive, emo- tional effects of opiates do not last. They are soon replaced by long-term negative changes in mood and emotion. These un- pleasant experiences are relieved for 30 to 60 minutes after each new injection of the drug, but they eventually color most of the rest of the person’s waking experience.

The opiates can induce nausea and vomiting among novice users, constrict the pupils of the eye, and disrupt the coordina- tion of the digestive system. Continued use of opiates decreases the level of sex hormones in both women and men, resulting in reduced sex drive and impaired fertility.

Some people mix cocaine and opiates into a mixture known as a speedball to enhance these subjective feelings. The following brief case describes the preparation of this combination of drugs and one heroin addict’s immediate reaction to the injection of a speedball.

Feelings After Injecting Heroin He pushes the plunger on the syringe, squirting water into the heroin powder, then strikes a match and waves it just under the metal lid. The liquid bubbles and the heroin quickly dissolves with very little heat required. That’s good, he thinks. Sometimes the dope is so good it needs hardly any fire to dissolve it. Next, he shakes in a couple of small rocks of cocaine from the foil wrapper and is impressed that they vanish immediately in the solution. He swirls the liquid around, rips open the filter from one of his Marl- boros, and uses the white fibers as a strainer through which to draw the liquid speedball into the syringe. He carefully places the loaded syringe between his teeth. He rolls up his sleeve, removes his belt with one hand, and takes a seat on the edge of the toilet. He wraps the belt tight around his right arm and hopes he can get a clean hit on one of the veins he watches come up. There, I’ll go there.

The needle point feels sharp going in, which is good; it means he’s got an unused needle. When he pulls back on the plunger a little stream of blood slithers up into the syringe, discoloring the slightly yellow liquid. He loosens the belt, careful not to dis- lodge the needle from the vein, takes a breath, and slowly pushes

who are dependent on cocaine must spend enormous amounts of money to support their habit. They may have to sell important assets, such as their homes and cars, in order to finance extended binges. Some people become involved in a variety of criminal activities in order to raise enough money to purchase drugs.

Prolonged use of amphetamines has also been linked to an increase in violent behavior, but it is not clear whether this phe- nomenon is due to the drug itself or to the lifestyles with which it is frequently associated. Some violence might be related to a drug-induced increase in paranoia and hostility. Statistics con- cerning drugs and violent crime are very difficult to interpret. The direct effects of the drug on human behavior are confounded with various economic and social factors that are associated with buying, selling, and using an expensive, illegal drug like cocaine.

People who discontinue taking stimulant drugs do not typi- cally experience severe withdrawal symptoms. The most com- mon reaction is depression. Long-term exposure to high doses of amphetamine can lead to a profound state of clinical depression, which is often accompanied by ideas of suicide.

opiates The opiates are drugs that have properties similar to those of opium. The natural source of opium is a poppy with a white flower. The main active ingredients in opium are morphine and codeine, both of which are widely used in medicine, particularly to relieve pain. They are available legally only by prescription in the United States. In Canada, small quantities of codeine are available without a prescription in over-the-counter painkillers and cough medicines. “Opioids” are synthetic versions of opium, and they are often used to reduce pain. Oxycodone (OxyContin) and hydrocodone (Vicodin) are examples of opioids. Their medical use has increased dramatically over the past 20 years, and they are also widely misused. Heroin is a synthetic opiate that is made by modifying the morphine molecule. It was originally marketed as an alternative to morphine when physicians believed, errone- ously, that heroin is not addictive.

The positive, emotional effects of opiates do not last. They are soon replaced by long-term negative changes in mood and emotion.

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States in recent years, primarily because more people are misusing opioid painkillers (Jones, Mack, & Paulozzi, 2013).

Long-term conSequenceS The effects of opiates on oc- cupational performance and health depend in large part on the amount of drugs that the person takes. At high doses, people who are addicted to opiates become chronically lethargic and lose their motivation to remain productive. At low doses, some people who use opiates for an extended period of time can remain healthy and work productively in spite of their addiction. This functioning is, of course, dependent on the person’s having easy and relatively inexpensive access to opiates. One possibility is being maintained by a physician on methadone, a synthetic opiate that is some- times used therapeutically as an alternative to heroin.

People who are addicted to opiates become preoccupied with finding and using the drug, in order to experience the rush and to avoid withdrawal symptoms. Tolerance develops rather quickly, and the person’s daily dose increases regularly until it eventually levels off and remains steady. Many of the severe health consequences of opiate use are the result of the lifestyle of the addict rather than the drug itself. The enormous expenses and difficulties associated with obtaining illegal opiates almost invariably consume all the person’s resources. The person typi- cally neglects housing, nutrition, and health care in the search for another fix. Heroin addicts are much more likely than other people in the general population to die from AIDS, violence, and suicide.

Sedatives, hypnotics, and Anxiolytics The families of drugs known as barbiturates and benzodiazepines are also known informally as tranquilizers, hypnotics, and seda- tives. Tranquilizers are used to decrease anxiety or agitation. Hyp- notics are used to help people sleep. Sedative is a more general term that describes drugs that calm people or reduce excitement (other than the relief of anxiety). The barbiturates, such as phe- nobarbital (Nembutal) and amobarbital (Amytal), were used for a variety of purposes, including the treatment of chronic anxiety. The benzodiazepines, which include diazepam (Valium) and al- prazolam (Xanax), have replaced the barbiturates in the treatment

the liquid into his arm. He pulls the needle out and dabs with his finger at the drop of blood left behind on his arm. As he does this, he feels the freeze in his arm from the cocaine. His arm feels numb. Then it reaches his stomach and mouth. His heart races. He tastes the medicinal flavor just as the first wave of rushes is reaching his brain. His stomach heaves. His scalp tingles and he gets a little scared at first—the wave of sensation is stronger than usual. He fights the urge to vomit, the heroin kicks in and the nau- sea retreats as the warm, heroin heat replaces the heart-thump- ing freeze caused by the cocaine. His heart starts to slow down, or so it seems. A quiet, hollow siren rages in his head. The familiar beads of perspiration crowd each other on his forehead, and one drops onto his arm when he bends over to begin cleaning every- thing up. He puts away his paraphernalia, threads his belt into his pants, and sits down again. Good stuff, very good, he thinks as he nods for a second.

Back on Houston Street now, he decides to have a cup of espresso in a little coffee shop he comes upon. Sitting back at a table with a view of the street, he savors the thick hot coffee, lights a cigarette, and blows the smoke to the ceiling. Nothing hurts, he thinks. The lousy job that he needs to hold onto, the flak he catches from his wife, the fact that he is turning 40 and doesn’t have anything to show for his life—none of it fazes him, but he still thinks about it. A spotty work history, no college, and rent that is three weeks late don’t matter right now. He feels warm, loose, and sexy. Was the waitress’s smile a flirt or was she smil- ing because she caught him nodding? Doesn’t matter. He smiles back and thinks maybe he can buy his wife a gold-plated necklace instead of the real one. It will look just like the one she pointed out anyway.

And that was what he did (Fernandez, 1998, pp. 72–73).

High doses of opiates can lead to a comatose state, severely depressed breathing, and convulsions. The number of people admitted to hospital emergency rooms for treatment of heroin overdoses increased substantially during the 1990s and has re- mained relatively stable since that time (see Figure 11.2). Acci- dental deaths due to drug overdoses have increased in the United

figure 11.2 unintentional Drug overdose Deaths by major types of Drugs, united States, 1999–2007 In 2007, the number of deaths attributed to opioid pain killers was almost double the number from cocaine and more than five times higher than those involving heroin. Source: Courtesy of the Centers for Disease Control.

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interferes with the people’s ability to recall what they have said or planned to say. Lapses in attention and concentration problems are frequent.

Long-term conSequenceS The issue of the addictive properties of cannabis remains controversial (Budney & Lile, 2009; Hall & Pacula, 2003). Some tolerance effects to THC have been observed in laboratory animals. Tolerance effects in humans remain ambiguous. Most evidence suggests that people do not develop tolerance to THC unless they are exposed to high doses over an extended period of time. Some people actually report that they become more sensitive (rather than less sensitive) to the ef- fects of marijuana after repeated use. This phenomenon is called reverse tolerance. Although reverse tolerance has been reported ca- sually by frequent users, it has not been demonstrated in a labora- tory situation, where dosage levels can be carefully controlled.

Withdrawal symptoms are unlikely to develop among oc- casional smokers of marijuana. People who have been exposed to continuous, high doses of THC may experience withdrawal symptoms, such as irritability, restlessness, and insomnia.

Prolonged heavy use of marijuana may lead to certain types of performance deficits on neuropsychological tests, especially those involving sustained attention, learning, and decision mak- ing. Follow-up studies of adults who used cannabis heavily over a period of several years have found some evidence of cognitive decline associated with the drug (Crean , Crane, & Mason, 2011; Pope & Yurgelun-Todd, 2004).

hallucinogens and related Drugs Drugs that are called hallucinogens cause people to experience hallucinations. Although many other types of drugs can lead to hallucinations at toxic levels, hallucinogens cause hallucinations at relatively low doses. There are many different types of halluci- nogens, and they have very different neurophysiological effects. The molecular structure of many hallucinogens is similar to the molecular structure of various neurotransmitters, such as sero- tonin and norepinephrine. The most common hallucinogen is a synthetic drug called LSD (d-lysergic acid diethylamide), which bears a strong chemical resemblance to serotonin. It achieves its effect by interacting with certain types of serotonin receptors in the brain. Psilocybin is another type of hallucinogen whose chem- ical structure resembles that of serotonin. It is found in differ- ent types of mushrooms, which grow primarily in the southern United States and Mexico. Mescaline is a type of hallucinogen that resembles norepinephrine. It is the active ingredient in a small, spineless cactus called peyote. Mescaline and psilocybin have been used in religious ceremonies by various Native Ameri- can peoples for many centuries.

MDMA (Methylene-Dioxy-Methamphetamine, also known as Ecstasy) is one of several synthetic amphetamine derivates. It could be classified as a stimulant, but most texts list it as a type of hallucinogen (Julien, Advokat, & Comaty, 2010). MDMA is also known as a “club drug” because it is popular among people

of anxiety disorders, in large part because of their lower potential for producing a lethal overdose.

Short-term effectS Sedatives and hypnotics can lead to a state of intoxication that is identical to that associated with alco- hol. It is characterized by impaired judgment, slowness of speech, lack of coordination, a narrowed range of attention, and disinhi- bition of sexual and aggressive impulses. Intravenous use of barbi- turates can lead quickly to a pleasant, warm, drowsy feeling that is similar to the experience achieved when taking opiates. The benzodiazepines can sometimes lead to an increase in hostile and aggressive behavior. Some clinicians call this a “rage reaction” or aggressive dyscontrol.

Long-term conSequenceS People who abruptly stop tak- ing high doses of benzodiazepines may experience symptoms that are sometimes called a discontinuance syndrome. These symptoms can include a return—and, in some cases, a worsening—of the original anxiety symptoms, if the medication was being used to treat an anxiety disorder. The person may also develop new symp- toms that are directly associated with drug withdrawal. These include irritability, paranoia, sleep disturbance, agitation, muscle tension, restlessness, and perceptual disturbances. Withdrawal symptoms are less likely to occur if the medication is discontin- ued gradually rather than abruptly.

cannabis Marijuana and hashish are derived from the hemp plant, Can- nabis sativa. The most common active ingredient in cannabis is a compound called delta-9-tetrahydrocannabinol (THC). Because every part of the plant contains THC, cannabis can be prepared for consumption in several ways. Marijuana refers to the dried leaves and flowers, which can be smoked in a cigarette or pipe. It can also be baked in brownies and ingested orally. Hashish refers to the dried resin from the top of the female cannabis plant. It can be smoked or eaten after being baked in cookies or brownies.

Oral administration of cannabis material leads to slow and incomplete absorption. Therefore, the dose must be two or three times larger to achieve the same subjective effect as when it is smoked. Most of the drug is metabolized in the liver.

Short-term effectS The subjective effects of marijuana are almost always pleasant. “Getting high” on marijuana refers to a pervasive sense of well-being and happiness. Laboratory research has shown that marijuana can have variable effects on a person’s mood. Many people begin to feel happy, but some become anx- ious and paranoid. The mood of other people seems to be espe- cially important. After smoking marijuana, a person’s mood may become more easily influenced by how other people are behaving.

Cannabis intoxication is often accompanied by temporal dis- integration, a condition in which people have trouble retaining and organizing information, even over relatively short periods of time. Conversations may become disjointed because the drug

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this process by constantly reminding them that the experience is drug-induced and will be over soon.

Most hallucinogens are not particularly toxic. People do not die from taking an overdose of LSD, psilocybin, or mescaline. However, PCP is much more toxic. High doses can lead to coma, convulsions, respiratory arrest, and brain hemorrhage. MDMA (Ecstasy) can damage serotonin neurons on a permanent basis, and it has been associated with some fatalities (Gold, Tabrah, & Frost-Pineda, 2001).

Long-term conSequenceS The use of hallucinogens fol- lows a different pattern than that associated with most other drugs. Hallucinogens, with the possible exception of PCP, are used sporadically and on special occasions rather than continu- ously. If these drugs are taken repeatedly, within two or three days, their effects disappear. Most people do not increase their use of hallucinogens over time. People who stop taking hallu- cinogens after continued use do not experience problems; there seem to be no withdrawal symptoms associated with the halluci- nogens that resemble serotonin and norepinephrine. The percep- tual effects of hallucinogenic drugs almost always wear off after several hours. There are cases, however, in which these drugs have induced persistent psychotic behavior. Most experts inter- pret these examples as an indication that the drug experience can trigger the onset of psychosis in people who were already vulner- able to that type of disorder. As genes involved in the predisposi- tion toward psychosis are identified, it will become possible to test this hypothesis.

Some people who have taken hallucinogens experience flash- backs—brief visual aftereffects that can occur at unpredictable intervals long after the drug has been cleared from the person’s body. Scientists do not understand the mechanisms that are re- sponsible for flashbacks. Flashbacks may be more likely to occur when the person is under stress or after the person has used an- other drug, such as marijuana.

Diagnosis The problems that we have reviewed indicate that substance use disorders represent an extremely diverse set of problems. Every- one—clinicians and researchers, as well as drug abusers and their families—seems to recognize the existence of a serious type of psychological disorder. But do these problems have a core? What is the best way to define them? In the following pages we briefly review some of the ways in which alcoholism and drug abuse have been defined. We must begin with the recognition that alcohol- ism and other types of addictions have not always been viewed as medical conditions that require treatment (Walters, 1999).

Brief history of Legal and Illegal Substances One of the most widely recognized facts about alcohol consump- tion is that drinking patterns vary tremendously from one culture to the next and, within the same culture, from one point in time

who attend “raves” and dance clubs (LSD and methamphetamine are also known as club drugs). MDMA is usually taken as a tablet, but the powder form can be inhaled or injected. Within half an hour of ingesting MDMA orally, the person begins to experience an enhanced mood state and a feeling of well-being that often lasts several hours. Although it does not produce vivid hallucinations, MDMA does lead to changes in perceptual experiences, such as distortions in the sense of time and space, as well as increased sen- sory awareness. It also produces changes in blood pressure and can interfere with the body’s ability to regulate its temperature.

Phencyclidine (PCP) is another synthetic drug that is often classified with the hallucinogens, although its effects are very differ- ent than those associated with LSD and mescaline. It was originally developed as a painkiller. Small doses of PCP lead to relaxation, warmth, and numbness. At higher doses, PCP can induce psy- chotic behavior, including delusional thinking, catatonic motor be- havior, manic excitement, and sudden mood changes. The drug is typically sold in a crystallized form that can be sprinkled on leaves, such as tobacco, marijuana, or parsley, and then smoked. Some people snort it or inject it after dissolving the crystals in water.

Short-term effectS The effects of hallucinogenic drugs are difficult to study empirically because they are based primarily in subjective experience. They typically induce vivid, and occasion- ally spectacular, visual images. During the early phase of this drug experience, the images often take the form of colorful geometric patterns. The later phase is more likely to be filled with mean- ingful images of people, animals, and places. The images may change rapidly, and they sometimes follow an explosive pattern of movement.

Although these hallucinatory experiences are usually pleas- ant, they are occasionally frightening. “Bad trips” are a decid- edly unpleasant experience that can lead to panic attacks and the fear of losing one’s mind. People can usually be talked through

MDMA is known as a “club drug” because it is popular among people who attend “raves” and dance clubs. It causes changes in perceptual experiences, such as distortions in the sense of time and space, as well as increased sensory awareness.

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such morally reprehensible behaviors (Okrent, 2010). The tem- perance movement was, in fact, able to persuade many thousands of people to abandon the consumption of alcohol.

The movement finally succeeded in banning the manufac- ture and sale of alcoholic beverages when Congress approved the Eighteenth Amendment to the Constitution in 1919. During the following years, known as the Prohibition era, the average con- sumption of alcohol fell substantially, and the incidence of associ- ated medical illnesses, such as cirrhosis of the liver, also declined. Nevertheless, these laws were extremely difficult to enforce, and Prohibition was repealed in 1933.

DSm-5 The diagnostic manual provides definitions of substance-related disorders for 9 different classes of drugs (see Table 11.1). There are two broad types of disorder listed under this broad heading: substance use disorders and substance-induced disorders. Sub- stance use disorders refer to the kinds of problems that come to mind for most of us when we think of someone being addicted to a drug (e.g., alcoholism). The problems that DSM-5 calls “substance-induced disorders” include primarily the immediate impact of taking a drug (intoxication) or discontinuing its re- peated use (withdrawal). DSM-5 provides separate sets of diag- nostic criteria for each different class of substances and for each type of problem under these classes. For example, with regard to alcohol, DSM-5 lists diagnostic criteria for alcohol use disorder, alcohol intoxication, and alcohol withdrawal. For the sake of ef- ficiency, we will focus on the diagnostic criteria for substance use disorders, and we will not describe the sets of diagnostic criteria for intoxication and withdrawal. You should note, however, that there are some variations across disorders. Caffeine is the only substance listed in DSM-5 for which the manual does not pro- vide a definition of substance use disorder; it only defines caffeine intoxication and caffeine withdrawal.

The workgroup that prepared the definition of substance use disorders for DSM-5 collapsed what used to be called substance dependence and substance abuse into a single definition of substance use disorder with a continuous range of severity. In the case of alcohol, this disorder is called alcohol use disorder. The specific features included in the list of criteria are essentially a combination of those formerly used to identify dependence and abuse, with at least two of the total features being required to reach threshold for a diagnosis. The rationale for this change is based on research evi- dence showing that dependence and abuse are not clearly distinct forms of disorder (Harford, Yi, & Grant, 2010).

The DSM-5 criteria for alcohol use disorder are presented in “DSM-5: Alcohol Use Disorder.” The person has to exhibit at least two of the eleven criteria within a 12-month period of time for a diagnosis of alcohol use disorder to be made. The severity of the disorder is also noted, based on the number of symptoms that are present: mild (2–3 symptoms), moderate (4–5 symptoms), or severe (6 or more symptoms). The first four symptoms listed in “DSM-5: Alcohol Use Disorder” can be described as indicating the

to another. Public attitudes toward the consumption of alcohol have changed dramatically during the course of U.S. history. For example, heavy drinking was not generally considered to be a se- rious problem in colonial times (Levine, 1978). In fact, it seemed to be an integral part of daily life. The average amount of alcohol consumed per person each year was much higher in those days than it is today. A typical American in the eighteenth century drank approximately 4 gallons of alcohol a year; the correspond- ing figure for our own society is about 2.5 gallons (Fingarette, 1988). Drunkenness was not considered to be either socially deviant or symptomatic of medical illness.

Public attitudes toward alcohol changed dramatically in the United States during the first half of the nineteenth century. Members of the temperance movement preached against the con- sumption of alcohol in any form. Temperance workers ardently believed that anyone who drank alcohol would become a drunk- ard. Their arguments were largely moral and religious rather than medical or scientific, and many of their publications included essays on the personality weaknesses that were associated with

During the Prohibition era in the United States (1922–1933), it was illegal to manufacture, transport, or sell alcoholic beverages. Nevertheless, alco- hol continued to be widely available from illegal sources, and the law was eventually changed. Similar efforts to control access to addicting drugs have failed in other countries.

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to a drug and the eventual onset of impaired control, evidence of social impairment, and onset of pharmacological symptoms, the timing with which a person moves through these phases can vary enormously. The best available information regarding the course of substance use disorders comes from the study of alcoholism. The specific course of this problem varies considerably from one person to the next. The only thing that seems to be certain is that periods of heavy use alternate with periods of relative abstinence, however short-lived they may be (Schuckit & Smith, 2011).

One influential study regarding the natural history of al- coholism examined the lives of 456 inner-city adolescents from Boston and 268 former undergraduate students from Harvard University (Vaillant, 2003). Initial information was collected in 1940, when the participants were adolescents. Follow-up infor- mation was collected every other year by questionnaire and every fifth year by physical examination. The college group has been followed until 70 years of age, and the core city group has been followed to age 60. At some point during their lives, 21 percent of the college men and 35 percent of the core city men met diag- nostic criteria for alcohol abuse, which the investigators defined as the presence of four or more problems in such areas as em- ployer complaints, marital and family difficulties, medical com- plications, and legal problems. As expected, the mortality rate was higher among men who abused alcohol than among those who did not. Heart disease and cancer were twice as common among the alcohol abusers, perhaps in part because they were also more likely to be heavy cigarette smokers.

Most of the alcoholic men went through repeated cycles of abstinence followed by relapse. The life course of alcohol abuse

person’s impaired control over use of alcohol. These include persis- tent and unsuccessful efforts to quit drinking as well as craving for alcohol. The next three symptoms address forms of social impairment that follow problematic drinking. Criteria 8 and 9 refer to patterns of risky use, such as drinking while driving or continuing to drink in spite of the onset of serious psychological or medical complications. Tolerance and withdrawal, which might be called the pharmacological criteria, are the last two symptoms included in the definition of alco- hol use disorder. People with a history of tolerance and withdrawal following repeated use of alcohol report more severe drug-related problems, greater intensity of exposure to drugs, and more comorbid conditions such as anxiety and depression (Schuckit, 2010).

DSM-5 provides separate definitions of substance use disor- der for each type of substance. Previous editions of the manual had employed generic definitions of substance dependence and substance abuse that were applied across different drugs, but that approach tended to conceal differences between the kinds of problems that are associated with various classes of drugs (Frances, First, & Pincus, 1995). For example, problematic use of opiates almost always involves pharmacological symptoms of tolerance and withdrawal, whereas repeated use of hallucinogens seldom does. In fact, most of the definitions of substance use dis- order are virtually identical.

course and outcome It is impossible to specify a typical course for substance use disorders, especially alcoholism. Age of onset varies widely, ranging from child- hood and early adolescence throughout the life span. Although we can roughly identify stages that intervene between initial exposure

DSM-5 criteria for Alcohol Use Disorder

A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Alcohol is often taken in larger amounts or over a longer

period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut

down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain

alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol. 5. Recurrent alcohol use resulting in a failure to fulfill major role

obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent

social or interpersonal problems caused or exacerbated by the effects of alcohol.

7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

8. Recurrent alcohol use in situations in which it is physically hazardous.

9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of alcohol to

achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the

same amount of alcohol. 11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal, pp. 499–500).

b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

298 CHAPTER 11 substance-related and addictive disorders

other Disorders commonly Associated with Addictions People with substance use disorders often exhibit other forms of mental disorder as well. Most prominent among these are antisocial personality disorder (ASPD), mood disorders, and anxiety disorders. Conduct disorder (the childhood manifes- tation of ASPD) is strongly related to concurrent alcohol use in adolescence and the subsequent development of alcohol de- pendence (McGue & Iacono, 2008). ASPD and alcohol/drug dependence frequently co-occur, and there is evidence to sug- gest that they represent alternative manifestations of a general predisposition toward behavioral disinhibition (Kendler et al., 2003).

The complexity of the association between substance use disorders and mood/anxiety disorders makes them difficult to untangle (Grant et al., 2006). In some cases, prolonged heavy drinking or use of psychoactive drugs can result in feelings of depression and anxiety. The more the person drinks or uses drugs, the more guilty the person feels about his or her inability to control the problem. In addition, continued use of alcohol and drugs often leads to greater conflict with family members, coworkers, and other people. Sometimes the depression and anxiety precede the onset of the substance use problem. In fact, some people seem to use alcohol and drugs initially in a futile attempt to self-medicate for these other conditions. Ultimately, the drugs make things worse.

Frequency Drug-related problems are found in most countries. There are interesting variations, however, in patterns of use for specific types of drugs. The use of specific drugs is determined, in part, by their availability. For example, opium is used most heavily in

could be charted most clearly for 121 of the core city men who abused alcohol and remained in the study until age 60 and 46 college men who abused alcohol and remained in the study until age 70. These data are illustrated in Figure 11.3. In the graphs in Figure 11.3, abstinence is defined as less than one drink per month for more than a year. Social drinking refers to problem-free drinking for 10 years or more. Controlled drink- ing is more than one drink per month for at least two years with no reported problem. The main differences between the groups were that the core city men began abusing alcohol at an earlier age, and they were also more likely than the college men even- tually to achieve stable abstinence. The average age of onset of alcohol abuse was 40 years for the college men and 29 years for the core city men.

Many men spent the previous 20 years alternating between pe- riods of controlled drinking and alcohol abuse. The proportion of men who continued to abuse alcohol went down after the age of 40. The proportion of alcoholic men in both groups who became completely abstinent went up slowly, but consistently during the follow-up period. The longer a man remained abstinent, the greater the probability that he would continue to be abstinent. These data indicate that relapse to alcohol abuse was unlikely among men who were able to remain abstinent for at least six years.

Many important questions remain to be answered about the relapse process. Is there a “safe point” that separates a period of high risk for relapse from a period of more stable change? Data from the study of men in Boston suggest that the six-year mark may be important for men who abuse alcohol. Will this sugges- tion be replicated in other studies? And does it generalize to other drugs? Do relapse rates stabilize over time? Is an addicted person more likely to succeed on a later attempt to quit than on an early attempt? Answers to these questions will be useful in the develop- ment of more effective treatment programs.

figure 11.3 Drinking Status of Alcoholic men at five-Year Intervals Results of a long-term follow-up study of two groups of alcoholics: 121 core city men (top) and 46 college men (bottom). The core city men be- gan abusing alcohol at a younger age and were more likely to achieve stable abstinence by age 60. Source: Based on Valliant. 1996. A Long-term Follow-up of Male Alcohol Abuse. Archives of General Psychiatry; 53: 243–249.

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25 percent abstain from drinking completely. Among all men and women who have ever used alcohol, roughly 20 percent will develop serious problems at some point in their lives as a conse- quence of prolonged alcohol consumption (Anthony, Warner, & Kessler, 1994).

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) collected information on substance use disorders and related mental health problems in a nation- ally representative sample of more than 43,000 adults (Grant et al., 2006). This study provides the most recent, comprehensive evidence regarding the prevalence of alcoholism in the United States. Results from the NESARC study indicate a lifetime prev- alence rate of 30 percent for some form of alcohol use disorder (combining the previous categories of alcohol abuse and alco- hol dependence from DSM-IV). Alcohol-related disorders are clearly among the most common forms of mental disorder in the United States. These problems most often went untreated; only 24 percent of the men and women who were assigned a diagnosis of alcohol dependence had ever received treatment for these problems.

genDer DIfferenceS Approximately 60 percent of women in the United States drink alcohol at least occasionally, but, in comparison to men, fewer develop alcoholism. Among people who chronically abuse or become dependent upon alcohol, men outnumber women by a ratio of approximately two to one. Figure 11.4 presents evidence regarding the 12-month prevalence of alcohol use disorder, as defined in DSM-5, among men and women who participated in the NESARC study (Agrawal, Heath, & Lynskey, 2011). Notice that, for all age groups, men are much more likely than women to qualify for the diagnosis.

Southeast Asia and in some Middle Eastern countries, where the opium poppy is cultivated. Cocaine is used frequently in certain countries of South America where coca trees grow; it is also im- ported into North America, particularly the United States. Use of cannabis is widespread around the world, in part because the plants can grow in many different climates. In contrast, in Japan, where the amount of land available for cultivation is severely limited, the largest drug problem involves amphetamine, a syn- thetic drug.

The fact that people in some regions are frequent drug us- ers does not necessarily imply that a particular population will have a high rate of substance dependence. Culture shapes people’s choices about the use of drugs and the ways in which they are used. It influences such factors as the amount of a drug that is typically ingested, the route of administration, and the person’s beliefs about drug effects (Room, 2007). These considerations, in turn, influence the probability that serious problems will de- velop. Consider, for example, the Indians of South America who produce coca for market. They have traditionally used the leaves as medicines and in religious ceremonies. They also roll the leaves into a ball that can be tucked in the cheek and sucked for an ex- tended period of time. This form of use relieves cold, hunger, and thirst. It does not produce the severe problems that are associated with the use of refined cocaine, a much more potent drug that can be sniffed or injected.

When we consider the frequency of drug addiction, we must keep in mind the distinction between using a drug and becom- ing addicted to it. Many people who use drugs do not become dependent on them. Nevertheless, people have to use the drug before they can become dependent, and the age at which they begin to use drugs is an important risk factor. For example, the prevalence rate for alcoholism among males who began drinking alcohol before the age of 14 is double than found among males who began drinking at age 18 (McGue et al., 2001). The same pattern is found among women; those who begin to use alcohol at an earlier age have a much higher risk of becoming addicted. It is not clear whether earlier initiation leads directly to increased risk of alcohol use disorder or whether people who are already predisposed toward the development of drinking problems sim- ply start using earlier.

Most people who occasionally use alcohol and illicit drugs do not become addicted. More serious problems almost always develop slowly after extended exposure to a drug. The average time between initial use of illicit drugs and the onset of symptoms of a substance use disorder is between two and three years (Anthony & Helzer, 1991). The distinction between people who eventually become ad- dicted and those who use drugs without becoming addicted is an important consideration in the study of psychopathology.

Prevalence of Alcohol use Disorder Approximately two out of every three males in Western coun- tries drink alcohol regularly, at least on a social basis; less than

Actor Robert Downey Jr. suffered through several years of serious drug- related problems. His successful recovery, which has lasted more than 10 years, offers hope to others who have struggled with similarly challenging additions.

300 CHAPTER 11 substance-related and addictive disorders

Prevalence of Drug and nicotine use Disorders The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) also reported the frequency of problems associated with other kinds of drugs (Compton et al., 2007). The combined lifetime prevalence for abuse of or dependence on any type of controlled substance (those that are illegal or avail- able only by prescription) was 10.3 percent. This is approxi- mately one-third the rate for alcohol abuse and dependence. As in the case of alcohol-related disorders, drug abuse and depen- dence were significantly more common among men than women. Lifetime prevalence rates generated by this study for substance use disorders associated with specific types of drugs are listed in Figure 11.5. Remember that DSM-IV (the diagnostic system used when these data were compiled) recognized two types of addiction, with substance dependence being the most severe and substance abuse being less severe.

The lifetime prevalence of nicotine dependence was re- ported to be 24 percent in the National Comorbidity Survey (Kessler et al., 1994). The percentage of adults in the United States who smoke tobacco has actually declined since 1964, when the U.S. Surgeon General’s Report announced it had found a definite link between smoking and cancer and other

Although the rate of alcoholism among younger women has increased, prevalence is still higher in men, and the rates do not seem likely to converge (Grant & Weissman, 2007; Grucza et al., 2008). Persistent differences can probably be attributed to social and biological variables. American culture traditionally has held a negative view of intoxication among women. Social disapproval probably explains why women are more likely than men to drink in the privacy of their own homes, either alone or with another person. Women, therefore, may be less likely than men to drink heavily because the range of situations in which they are expected to drink, or in which they can drink without eliciting social dis- approval, is narrower.

Biologically, there are also important gender differences in alcohol metabolism. A single standard dose of alcohol, measured in proportion to total body weight, will produce a higher peak blood alcohol level in women than in men. One explanation for this difference lies in the fact that men have a higher average con- tent of body water than women do. A standard dose of alcohol will be less diluted in women because alcohol is distributed in total body water. This may help to explain the fact that women who drink heavily for many years are more vulnerable to liver disorders than are male drinkers.

figure 11.4 gender Differences in Substance use Disorders Lifetime prevalence of substance use disorders in the United States. Source: Based on Agrawal, A., Heath, A. C., & Lynskey, M. T. 2011. DSM-IV to DSM-5: The impact of proposed revisions on diagnosis of alcohol use disorders. Addiction; 106: 1935–1943.

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figure 11.5 frequency of Drug use Disorders Lifetime prevalence of prob- lems associated with specific types of drugs in the United States (using DSM-IV definitions of abuse and dependence). Source: Based on data from W. M. Compton, et al. 2007. Prevalence, Correlates, Disabilities, and Comorbidities of DSM-IV Drug Abuse and Dependence in the United States. Archives of General Psychiatry; 64: 566–576.

substance-related and addictive disorders CHAPTER 11 301

among the elderly (Hasin et al., 2007). Most elderly alcohol abusers are people who have had drinking problems for many years.

The use of illegal drugs is relatively infrequent among the elderly, but there is a problem associated with their abuse of, and dependence on, prescription drugs and over-the-counter medica- tions, especially hypnotics, sedatives, anxiolytics, and painkillers. The elderly use more legal drugs than do people in any other age group. One estimate suggested that 25 percent of all people over the age of 55 use psychoactive drugs of one kind or another (Beynon, McVeigh, & Roe, 2007). The risk for substance use dis- orders among the elderly is increased by frequent use of multiple psychoactive drugs combined with enhanced sensitivity to drug toxicity (caused by slowed metabolic breakdown of alcohol and other drugs).

The following case illustrates several issues that are associ- ated with substance use disorders among the elderly, including the abuse of alcohol together with abuse of prescription medi- cations, the presence of prominent symptoms of anxiety and

diseases (see Critical Thinking Matters). The rate of decline has been greatest among men, who traditionally have smoked more than women. Among people between the ages of 18 and 25, however, smoking rates increased during the 1990s (Chaloupka, 2005). Furthermore, although overall tobacco consumption has declined in industrialized countries, it has increased dramati- cally in the developing countries, where people may be less edu- cated about the health risks associated with smoking (McKim, 2000).

risk for Addiction Across the Life Span Older people do not drink as much alcohol as younger people. The proportion of people who abstain from drinking alcohol is only 22 percent for people in their thirties, goes up to 47 percent for people in their sixties, and is approximately 80 percent for people over 80 years of age. Figure 11.4 illustrates 12-month prevalence rates for DSM-5 alcohol use disorder in the United States among different age groups. Prevalence rates are substantially higher among young adults and lowest

CriTiCaL Thinking matters

Should Tobacco Products Be Illegal?

In 1996, the U.S. Food and Drug Administration (FDA) issued a regulation prohibiting the sale and distribution of tobacco products to children and adolescents. They remain legally available to adults. Previous efforts to limit smoking had focused more narrowly on restricting smoking in public places, eliminat- ing cigarette advertisements on television, and increasing sales taxes. The new rule asserted that, as a drug, nicotine should be controlled by the government. The decisions behind this regulation raise a number of critical thinking issues with regard to substance use disorders. How does the FDA decide whether a product is a drug? Should the government control people’s access to addicting drugs? If so, what is the best way to control access?

The FDA conducted an extensive investigation to examine the effects of tobacco products and to determine whether they were designed by their manufacturers to deliver nicotine to consumers. Independent research studies as well as documents from the tobacco industry’s own laboratories pointed to the conclusion that nicotine is addictive (Dreyfuss, 1996). People who use tobacco products clearly develop symptoms of dependence, including tolerance, withdrawal, and a pat- tern of compulsive use. In fact, nicotine is one of the most addicting drugs, viewed in terms of the high proportion of people who become dependent if they use the drug for some period of time.

After officially recognizing that nicotine is an addicting drug, the FDA could have banned tobacco products entirely (because they are not safe for human consumption). Another option would have been to require a complete elimination of nicotine from cigarettes.

The FDA did not consider these options to be practical or politically viable. Because so many adults are already addicted to nicotine, ex- tensive black markets would spring up immediately, similar to those involved with other illegal drugs. An outright ban on nicotine would fail, just as efforts to ban other drugs have failed (Husak, 2002; MacCoun, Reuter, & Wolf, 2001).

The FDA decided instead to approach the nicotine problem by invoking its authority to regulate medical devices (and treating cigarettes as a type of drug-delivery system). The tobacco regula- tions imposed by the FDA are prevention efforts designed to break the cycle of addiction to nicotine. They prohibit the sale of tobacco products to anyone under 18 years old and also severely restrict advertising (Cooper, 1994). Nicotine addiction almost always begins during adolescence. The FDA regulations are intended to reduce the rate at which young people are recruited to become new smok- ers and to minimize future health casualties from tobacco use.

This policy represents a moderate and thoughtful approach to the problem of nicotine dependence. It is a compromise between two extreme alternatives: allowing completely open access to a danger- ous drug or attempting to ban it completely. Preliminary evidence suggests that the FDA regulations regarding tobacco products have been modestly successful. Between 1997 and 2004, preva- lence rates for current smoking among adults in the United States dropped from 25 percent to 21 percent (Schiller et al., 2005). Public policy will not be able to eliminate completely the use of harmful drugs by adults in our society. It can reduce the risk of dependence, however, by minimizing their use at an early age.

302 CHAPTER 11 substance-related and addictive disorders

understand how addicting drugs affect the brain in order to un- derstand the process of dependence. At the same time, we need to understand the social and cultural factors that influence how and under what circumstances an individual first acquires and uses drugs. Our expectations about the effects of drugs are shaped by our parents, our peers, and the media. These are also important etiological considerations.

The causes of alcoholism are best viewed within a develop- mental framework that views the problem in terms of various stages: (1) initiation and continuation, (2) escalation and transi- tion to abuse, and (3) development of tolerance and withdrawal (Leonard et al., 2000; Tarter, Vanyukov, & Kirisci, 2008). In the following pages we review some of the social, psychological, and biological factors that explain why people begin to drink, how their drinking behaviors are reinforced, and how they develop tolerance after prolonged exposure.

Social factors People who don’t drink obviously won’t develop alcoholism, and culture can influence that decision. Some cultures prohibit or actively discourage alcohol consumption. Many Muslims, for example, believe that drinking alcohol is sinful. Other reli- gions encourage the use of small amounts of alcohol in religious ceremonies—such as Jewish people drinking wine at Passover seders—while also showing disdain for those who drink to the point of intoxication (Johnson, 2007). This type of cultural con- straint can decrease rates of alcohol use disorder. In one large epidemiological study, for example, Jews had significantly lower rates of alcoholism than Catholics and Protestants (Yeung & Greenwald, 1992).

depression, and the tendency to deny the extent of their use or abuse of drugs.

Ms. E’s Drinking Ms. E is an 80-year-old woman who was brought in for an evalua- tion by her daughters because they noticed depressive symptoms, appetite disturbance, and memory deficits. She denied all prob- lems related to her daughters’ concerns. She had a depressed af- fect, mild psychomotor agitation, and decrements of recent and remote memory. She was disoriented to time. She verbalized state- ments of guilt and self-deprecation. She denied ever drinking alco- hol, which was corroborated by the daughter with whom she lived but was refuted by her other daughter, who stated that Ms. E drank one or two glasses of brandy almost every day. She had been tak- ing various barbiturates for “nerves” for over 30 years. The dosage she ingested gradually increased over the years, and she frequently took more medications than were prescribed. Because it was un- clear if her symptoms were related to her barbiturate use, she re- luctantly agreed to be slowly and gradually detoxified. She refused a dementia work-up. Once detoxification was complete, her affect and appetite were improved, but her cognitive deficits were un- changed. Several months later, she and her family dropped out of treatment. She was reportedly drinking brandy, wine, and “hard liquor” every afternoon and evening, with her hired caregiver mix- ing the drinks (Solomon et al., 1993).

Diagnostic criteria for substance use disorders are sometimes difficult to apply to the elderly, primarily because drug use has somewhat different consequences in their lives. Tolerance to many drugs is reduced among the elderly, and the symptoms of withdrawal may be more severe and prolonged. They are less likely to suffer occupational impairment because they are less fre- quently employed than younger people. The probability of so- cial impairment may be reduced because elderly people are more likely to live apart from their families.

Causes Our discussion of causal factors will focus primarily on alcohol use disorder. We have chosen this approach because clinical scientists know more about alcohol and its abuse than about any of the other drugs. Twin studies also suggest that alcohol dependence and other forms of drug dependence share a common etiology (Kendler & Prescott, 2006). Research on alcohol use disorder illustrates factors that are also important in the etiology of other forms of addiction.

Most contemporary investigators approach the develop- ment of alcoholism in terms of multiple systems (Sher, Grekin, & Williams, 2005). Biological factors obviously play an important role. The addicting properties of certain drugs are crucial: Peo- ple become addicted to drugs like heroin, nicotine, and alcohol, but they do not become addicted to drugs like the antidepres- sants or to food additives like Nutrasweet. We must, therefore, Source: www.cartoonbank.com

substance-related and addictive disorders CHAPTER 11 303

coupled with reduced parental monitoring, increases the prob- ability that an adolescent will affiliate with peers who use drugs (Chassin & Handley, 2006). Peer and sibling substance use are robust predictors of adolescent alcohol and drug use, even more than parental alcohol use. The impact of friends’ alcohol use is greater among adolescent girls than adolescent boys.

Biological factors Initial physiological reactions to alcohol can have a dramatic neg- ative influence on a person’s early drinking experiences. For exam- ple, millions of people are unable to tolerate even small amounts of alcohol. These people develop flushed skin, sometimes after only a single drink. They may also feel nauseated, and some ex- perience an abnormal heartbeat. This phenomenon is most com- mon among people of Asian ancestry and may affect 30 to 50 percent of this population. The adverse reaction is due to genetic variants in the ADH and ALDH genes, which are involved in the metabolism of alcohol, and are much more common in Asian populations than in other races (Dick & Foroud, 2003). Not co- incidentally, the prevalence of alcoholism is unusually low among Asian populations. Research studies indicate a link between these two phenomena. For example, Japanese Americans who experi- ence the fast-flushing response tend to drink less than those who do not flush (Chen & Yin, 2008). The basic evidence suggests that in addition to looking for factors that make some individu- als especially vulnerable to the addicting effects of alcohol, it may also be important to identify protective factors that reduce the probability of substance dependence.

A person’s initial use of addictive drugs is obviously one im- portant step toward the development of substance dependence, but the fact remains that most people who drink alcohol do not develop alcoholism. What accounts for the next important phase of the disorder? Why do some people abuse the drug while oth- ers do not? In the following pages, we outline several additional biological variables. We begin by examining genetic factors, and then we consider the neurochemical effects of the drugs themselves.

genetIcS of ALcohoLISm An extensive literature attests to the fact that patterns of alcohol consumption, as well as psycho- logical and social problems associated with alcohol abuse, tend to run in families. The lifetime prevalence of alcoholism among the parents, siblings, and children of people with alcoholism is at least three to five times higher than the rate in the general population (MacKillop, McGeary, & Ray, 2010). Of course, this elevated risk among first-degree relatives could reflect the influ- ence of either genetic or environmental factors, because families share both types of influences. Therefore, we must look to the results of twin and adoption studies in an effort to disentangle these variables.

Several twin studies have examined twin concordance rates when the proband meets diagnostic criteria for substance depen- dence. Concordance rates are higher among MZ than among DZ

Among those young people who choose to drink alcohol (or smoke cigarettes, or consume other addictive substances), which ones will eventually develop problems? The development of addiction requires continued use, and it is influenced by the manner in which the drug is consumed. In other words, with re- gard to alcohol, will the person’s initial reaction to the drug be pleasant, or will he or she become sick and avoid alcoholic bever- ages in the future? If the person continues drinking, will he or she choose strong or weak drinks, with or without food, with others or alone, and so on?

Several studies have examined social factors that predict sub- stance use among adolescents. Initial experimentation with drugs is most likely to occur among those individuals who are rebellious and extroverted and whose parents and peers model or encourage use (Chassin et al., 2003). The relative influence of parents and friends varies according to the gender and age of the adolescent as well as the drug in question.

Parents can influence their children’s drinking behaviors in many ways. They can serve as models for using drugs to cope with stressful circumstances. They may also help promote atti- tudes and expectations regarding the benefits of drug consump- tion, or they may simply provide access to licit or illicit drugs (Kirisci et al., 2007). Adolescents with alcoholic parents are more likely to drink alcohol than those whose parents do not abuse al- cohol. This increased risk seems to be due to several factors, in- cluding the fact that alcoholic parents monitor their children’s behavior less closely, thereby providing more opportunities for illicit drinking. Parental monitoring and discipline have an im- portant impact on adolescent substance use; higher parental monitoring is associated with reduced risk of tobacco and alcohol use ( Latendresse et al., 2008).

The level of negative affect is also relatively high in the families of alcoholic parents. This unpleasant emotional climate,

The circumstances in which an adolescent is initially exposed to alcohol can influence the person’s pattern of drinking. Drinking small amounts of wine with meals or during religious ceremonies may be less likely to lead to alcohol dependence than the sporadic consumption of hard liquor for the purpose of becoming intoxicated.

304 CHAPTER 11 substance-related and addictive disorders

What exactly is inherited as the predisposition toward al- cohol dependence? Some of the genes that influence the risk of developing alcohol dependence are genes involved in the metabo- lism of alcohol, such as the ADH and ALDH genes (discussed earlier and related to the skin flushing response). Other genes that alter the risk for alcohol dependence may be genes involved in personality traits (Dick, 2007; Spanagel et al., 2010). For ex- ample, to the extent that genes influence novelty seeking and sensation seeking, these genes may also increase the person’s risk for alcohol dependence because the person is more likely to par- ticipate in dangerous patterns of consumption (such as drinking several shots of liquor in rapid succession rather than sipping beer or wine).

neuroAnAtomY AnD neurochemIStrY All of the ad- dicting drugs produce changes in the chemical processes by which messages are transmitted in the brain, including systems that in- volve catecholamines (for example, dopamine, norepinephrine, and serotonin), as well as the neuropeptides. In the following sections, we will outline some of the ways in which psychoactive drugs influence neural transmission and the areas of the brain in which these effects are most pronounced.

Dopamine anD RewaRD pathways Scientists who study the biological basis of addiction have devoted a considerable amount of their attention to understanding the rewarding or reinforcing properties of drugs (Koob, 2006; Self & Tamminga, 2004). People may become dependent on psychoactive drugs because they stimulate areas of the brain that are known as “re- ward pathways” (see Figure 11.6). One primary circuit in this pathway is the medial forebrain bundle, which connects the ventral tegmental area to the nucleus accumbens. Connections

twin pairs. For example, one study analyzed data from a large sample of twins in Australia. The investigators found concordance rates for alcohol dependence of 56 percent in male MZ twins and 33 percent in male DZ twins (Heath et al., 1997). Correspond- ing figures for MZ and DZ female twin pairs were 30 percent and 17 percent, respectively. Differences between MZ and DZ concordance rates were significant for both genders. The fact that concordance rates were higher for men than for women reflects the much higher prevalence rate for alcoholism among men. Her- itability estimates were the same for both men and women, with approximately two-thirds of the variance in risk for alcoholism being produced by genetic factors.

The strategy followed in an adoption study (see Chapter 2) allows the investigator to separate relatively clearly the influ- ence of genetic and environmental factors. Probands in this type of study are individuals who meet two criteria: (1) They had a biological parent who was alcoholic, and (2) they were adopted from their biological parents at an early age and raised by adop- tive parents. Investigators then locate these individuals when they have become adults and determine the frequency of alcoholism as a function of both biological and environmental background. The results of adoption studies are consistent with the data from twin studies and point toward the influence of genetic factors in the etiology of alcohol use disorder (Agrawal & Lynskey, 2008). The offspring of alcoholic parents who are reared by nonalco- holic adoptive parents are more likely than people in the general population to develop drinking problems of their own. Thus, the familial nature of alcoholism is at least partially determined by genes. Being reared by an alcoholic parent, in the absence of other etiological factors, does not appear to be a critical consider- ation in the development of the disorder.

figure 11.6 reward Pathways in the Brain Dopamine neurons in the ventral tegmental area communicate with the nucleus accumbens, which also connects to the prefrontal cortex, an area involved in planning and judgment. This pathway also involves connections to the amygdala, which play an important role in processing emotional reactions. Source: © Pearson Education, Upper Saddle River, New Jersey.

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Ventral tegmenta area

substance-related and addictive disorders CHAPTER 11 305

limbic areas of the brain as well as the medial prefrontal cortex (Tomkins & Sellers, 2001). Furthermore, when people who are dependent on cocaine are exposed to cues that have previously signaled drug use, their medial prefrontal cortex becomes acti- vated, suggesting that this area of the brain is involved in feelings of drug craving. Watch the Video The Brain’s Reward System on MyPsychLab

The effects of alcohol on reward pathways in the brain are more complex and less clearly understood than the effects of many other drugs (Durazzo et al., 2010). Alcohol clearly affects several different types of neurotransmitters. It may stimulate the mesolimbic dopamine pathway directly, or it may act indirectly by decreasing the activity of GABA neurons (which normally inhibit dopamine neurons). Interesting findings from genetic studies support the latter possibility. Several genes that affect GABA reception have been identified as influencing the risk for alcohol dependence (Covault et al., 2004; Radel et al., 2005).

from these structures to the frontal and prefrontal cortex as well as areas of the limbic system, such as the amygdala, also mod- erate the influence of reward. For many years, scientists have known electrical stimulation of the medial forebrain bundle can serve as a powerful source of positive reinforcement for animals as they perform an operant learning task. Natural rewards, such as food and sex, increase dopamine levels in certain crucial sec- tions of this pathway, which is also known as the mesolimbic dopamine pathway.

Drugs of abuse have a dramatic effect on brain reward path- ways. Some points at which different drugs influence the dopa- mine pathway between the ventral tegmental area and the nucleus accumbens are illustrated in Figure 11.7. For example, stimulants such as amphetamine and cocaine affect reward pathways by in- hibiting the reuptake of dopamine into nerve terminals. Brain imaging studies with human participants have found that the administration of cocaine increases dopamine concentrations in

figure 11.7 neurochemical mechanisms of Drug Action Effects of psychoactive drugs on dopamine activity in reward pathway from the ventral tegmental area (VTA) to the nucleus accum- bens (NAcc). Source: Based on D. M. Tomkins and E. M. Sellers. 2001. Addiction and the Brain: The Role of Neurotransmitters in the Cause and Treatment of Drug Dependence. Canadian Medical Association Journal; 164: 817–821.

GABA interneuron tonically suppresses dopamine cell firing, resulting in reduced NAcc dopamine release.

Opioids, nicotine and alcohol can block the inhibitory control exerted by the neurons over the VTA dopamine cell bodies, resulting in increased VTA dopamine activity.

Dopamine cell body Activation results in the release of dopamine in the NAcc.

Opioids, nicotine and alcohol can stimulate the dopamine cell body directly by interacting with specific receptors on its surface and/or indirectly by altering the activity of other neurotransmitter inputs projecting from distal brain areas.

Dopamine transporter recycles some of the released dopamine back into the nerve terminal.

Cocaine and amphetamines block reuptake of dopamine, which accumulates in the synapse where it can further stimulate dopamine receptors. Amphetamines also cause dopamine release.

Dopamine Released dopamine interacts with postsynaptic dopamine receptors, resulting in reward.

VT A

NA cc

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alcohol. Expectations account for many effects that are sometimes assumed to be products of the drug itself (Moss & Albery, 2009). For example, subjects who believed that they had ingested alco- hol but who had actually consumed only tonic water display exag- gerated aggression and report enhanced feelings of sexual arousal (Testa et al., 2006). Much less is known about expectancies for drugs other than alcohol, but there is good reason to believe that these cognitive factors also influence the ways in which people re- spond to cannabis, nicotine, stimulants, anxiolytics, and sedatives.

Many studies have examined the specific nature of alcohol expectancies (Nicolai et al., 2010). Investigators asked people, Why do you drink? What do you expect to happen after you have consumed a few beers or a couple of glasses of wine? Subjects’ answers to these questions fit into six primary categories:

1. Alcohol transforms experiences in a positive way (for exam- ple: Drinking makes the future seem brighter).

2. Alcohol enhances social and physical pleasure (for exam- ple: Having a few drinks is a nice way to celebrate special occasions).

3. Alcohol enhances sexual performance and experience (for ex- ample: After a few drinks, I am more sexually responsive).

4. Alcohol increases power and aggression (for example: After a few drinks, it is easier to pick a fight).

5. Alcohol increases social assertiveness (for example: Having a few drinks makes it easier to talk to people).

6. Alcohol reduces tension (for example: Alcohol enables me to fall asleep more easily).

These expectations may constitute one of the primary reasons for continued and increasingly heavy consumption of alcoholic beverages. In fact, expectancy patterns can help pre- dict drinking behaviors. Longitudinal studies have found that adolescents who are just beginning to experiment with alcohol and who initially have the most positive expectations about the

enDogenous opioiD peptiDes One of the most interest- ing and important advances in neuroscience research was the discovery of the endogenous opioids known as endorphins and enkephalins. These relatively short chains of amino acids, or neu- ropeptides, are naturally synthesized in the brain and are closely related to morphine in their pharmacological properties. Opioid peptides possess a chemical affinity for specific receptor sites, in the same way that a key fits into a specific lock. Several types of opioid peptides are distributed widely throughout the brain. They appear to be especially important in the activities associ- ated with systems that control pain, emotion, stress, and re- ward, as well as such biological functions as feeding and growth (Froehlich, 1997).

Research studies have demonstrated many interesting fea- tures of the endorphins. Laboratory animals can develop toler- ance to injections of endorphins, just as they develop tolerance to addicting drugs like morphine, and they also exhibit symptoms of withdrawal if the injections are suddenly discontinued. These studies confirm the pharmacological similarity between endog- enous and exogenous opioids.

Some theorists associate alcoholism with exaggerated acti- vation of the endogenous opioid system in response to alcohol stimulation (Gianoulakis, DeWaele, & Thavundayil, 1996). Sev- eral lines of evidence support this hypothesis. One is that opi- oid receptor antagonists (drugs that block the effects of opioid peptides) produce a decrease in alcohol self-administration in laboratory animals. Another important bit of information comes from drug trials with human participants: When alcoholic pa- tients take naltrexone, an antagonist of endogenous opioids, they drink less alcohol and report that the subjective “high” as- sociated with drinking is noticeably diminished (see the section on treatment with medication, later in this chapter). Finally, in both rodents and humans, a genetic predisposition toward in- creased consumption of alcohol is associated with high levels of opioid system response to the ingestion of alcohol (Froehlich, 1997). For all of these reasons, it seems likely that endogenous opioid peptides are somehow involved in mediating alcohol dependence.

Psychological factors Genetic factors and neurochemistry undoubtedly account for many of the problems associated with addictive drugs, but as the systems perspective indicates, biological explanations are not in- compatible with psychological ones. In fact, extensive research over the past several decades has found that the progression of substance use disorders depends on an interaction between psy- chological and biological factors. Drug effects interact with the person’s beliefs and attitudes, as well as with the social context in which the drugs are taken.

exPectAtIonS ABout Drug effectS Placebo effects dem- onstrate that expectations are an important factor in any study of drug effects (see Chapter 3). This is certainly true in the case of

Common expectations about the effects of drinking alcohol include the notion that it enhances sexual arousal and experience.

substance-related and addictive disorders CHAPTER 11 307

have demonstrated that adolescents’ expectations about the ef- fects of alcohol are useful in predicting which individuals will later develop drinking problems (Jones, Corbin, & Fromme, 2001). Positive expectancies about alcohol, which are likely to encourage people to drink, are especially influential. Negative expectancies are associated with diminished use but seem to be less powerful.

Integrated Systems Alcoholism and other forms of addiction clearly result from an interaction among several types of systems. Various so- cial, psychological, and biological factors influence the per- son’s behavior at each stage in the cycle, from initial use of the drug through the eventual onset of tolerance and withdrawal.

researCh methods

Studies of People at Risk for Disorders

We have used the term risk informally throughout this book to refer to a hazard—the possibility of suffering harm. In scientific research, a risk is a statement about the probability that a certain outcome will occur. For example, the NCS found that the risk that a person in the United States will de- velop alcoholism at some point in his or her life is about 14 in 100. The combined risk for all types of illegal and controlled substances (such as cannabis, cocaine, heroin, and barbiturates) is about 8 in 100. The concept of risk implies only probability, not certainty. Someone who is “at risk” may or may not suffer harm, depending on many other events and circumstances. For example, men are at greater risk than women for the development of alcoholism, but that does not mean that all men will become alcoholics.

Risk factors are variables that are associated with a higher prob- ability of developing a disorder. Notice that this use of the term risk implies association, not causality. The concept of risk simply reflects a correlation between the risk factor and the disorder. Some risk factors are demographic variables, such as gender and race. Others are biological and psychological variables. In the case of alcoholism, and many other types of psychopathol- ogy, family history of the disorder is an important risk factor. Expectancies about the effects of drugs represent another important risk factor for alcoholism. People who expect that alcohol will reduce tension or transform experiences in a positive way are more likely to drink frequently and heavily than those who have negative expectancies about the effects of alcohol.

In order to determine whether certain risk factors might play a causal role in the development of the disorder, it is often neces- sary to conduct longitudinal studies (see Research Methods in Chapter 8). The investigator collects information about each person before the onset of the disorder. He or she can therefore

determine whether the risk factor is present before or only after the onset of symptoms. In other words, do people believe that alcohol reduces tension before they start to drink heavily, or do they develop this belief after they have been drinking heavily for some time? Longitudinal studies can be extremely expensive, and often they take several years to complete. They also require large numbers of participants because everyone in the study will not go on to develop the disorder in question.

Some of these shortcomings of longitudinal studies are especially relevant to research on substance abuse disorders. The risk for developing such disorders is quite low in the general population. For example, even though alcoholism is one of the most prevalent forms of mental disorder, a longitudinal study that follows the development of 100 randomly selected people from childhood to middle age will find only about 14 alcoholic adults (based on NCS data). Thus, to collect a useful amount of data, researchers need to study a large sample, which can be very expensive.

Recognition of this problem led scientists to develop special methods to increase the productivity of longitudinal research. One important technique is the high-risk research design. In high-risk research, subjects are selected from the general population based on a well-documented risk factor (Knop et al., 2003; Tarter & Vanyukov, 2001). A number of risk factors might be used to select subjects: positive family history for a given disorder, the presence of certain psychological characteristics, or perhaps a set of demographic variables such as age, gender, and/or race. High-risk research studies are designed to follow their participants over time, beginning before the onset of seri- ous disorders. They hope to identify factors that increase or decrease the probability that people who are vulnerable to a disorder will eventually develop its active symptoms.

effects of alcohol go on to consume greater amounts of alco- holic beverages (Smith et al., 1995). This type of demonstration is important because it indicates that, in many cases, the expec- tations appear before the person begins to drink heavily. There- fore, expectations may play a role in the onset of the problem rather than being consequences of heavy drinking (see Research Methods).

Where do these expectations come from, and when do they develop? In some cases they may arise from personal ex- periences with alcohol, but they can also be learned indirectly. Many adolescents hold strong beliefs about the effects of alco- hol long before they take their first drink. These expectations are influenced by a variety of environmental factors, including parental and peer attitudes as well as the portrayal of alcohol in the mass media (Agrawal & Lynskey, 2008). Follow-up studies

308 CHAPTER 11 substance-related and addictive disorders

only a relatively small number seek professional help. When they do enter treatment, it is typically with reluctance or on the insis- tence of friends, family members, or legal authorities. Compli- ance with treatment recommendations is often low, and dropout rates are high. The high rate of comorbidity with other forms of mental disorder presents an additional challenge, complicat- ing the formulation of a treatment plan. Treatment outcome is likely to be least successful with those people who have comor- bid conditions.

The goals of treatment for substance use disorders are a matter of controversy. Some clinicians believe that the only ac- ceptable goal is total abstinence from drinking or drug use. Oth- ers have argued that, for some people, a more reasonable goal is the moderate use of legal drugs. Important questions have also been raised about the scope of improvements that might be ex- pected from a successful treatment program. Is the goal simply to minimize or eliminate drug use, or should we expect that treatment will also address the social, occupational, and medical problems that are typically associated with drug problems? Get- ting Help at the end of this chapter offers additional resources for those seeking help and information on recovering from sub- stance abuse.

Detoxification Alcoholism and related forms of drug abuse are chronic condi- tions. Treatment is typically accomplished in a sequence of stages, beginning with a brief period of detoxification—the removal of a drug on which a person has become dependent—for three to six weeks (Coombs, Howatt, & Coombs, 2005). This process is often extremely difficult, as the person experiences marked symp- toms of withdrawal and gradually adjusts to the absence of the drug. For many types of CNS depressants, such as alcohol, hyp- notics, and sedatives, detoxification is accomplished gradually. Stimulant drugs, in contrast, can be stopped abruptly (Schuckit, 2005). Although detoxification usually takes place in a hospital, some evidence indicates that it can be accomplished with close supervision on an outpatient basis.

People who are going through alcohol detoxification are of- ten given various types of medications, including benzodiazepines and anticonvulsants, primarily as a way of minimizing withdrawal symptoms (O’Brien & McKay, 2007). This practice is controver- sial, in part because many people believe that it is illogical to use one form of drug, especially one that can be abused itself, to help someone recover from dependence on another drug.

medications During remission Following the process of detoxification, treatment efforts are aimed at helping the person maintain a state of remission. The best outcomes are associated with stable, long-term abstinence from drinking. Several forms of medication are used to help the person achieve this goal.

Furthermore, it appears that different influences are important at different stages of use. The process seems to progress in the following way. Initial experimentation with drugs is influenced by the environment—the person’s family, peers, school, and neighborhood (Rhee et al., 2003). Other people also influ- ence the person’s attitudes and expectations about the effects of drugs. Access to drugs, in addition to the patterns in which they are originally consumed, is determined, in part, by cul- tural factors.

For many people, drinking alcohol leads to short-term posi- tive effects that reinforce continued consumption. The exact psy- chological mechanisms that are responsible for reinforcing heavy drinking may take several different forms. They may involve diminished self-awareness, stress reduction, or improved mood. These effects of alcohol on behavior and subjective experience are determined, in part, by the person’s expectations about the way in which the drug will influence his or her feelings and behavior (Baer, 2002).

Genetic factors play an important role in the etiology of alcoholism. After the person has begun to use alcohol, genetic factors become increasingly important in shaping patterns of use (Dick et al., 2007). There are most likely several different types of genetic influences. Genes interact strongly with environmental events for certain types of the disorders. A genetic predisposition to alcohol dependence probably causes the person to react to alco- hol in an abnormal fashion. It is not clear whether those who are vulnerable to alcoholism are initially more or less sensitive than other people to the reinforcing effects of alcohol. Research studies have demonstrated both patterns of response (Sher, Grekin, & Williams, 2005).

The biological mechanisms responsible for abnormal reac- tions to alcohol seem to involve several interrelated neurotrans- mitter systems (Hyman & Malenka, 2001). Dopamine activity in the brain’s reward pathway is stimulated by alcohol as well as other drugs of abuse. Another important consideration may be a deficiency in serotonin activity in certain areas of the limbic system. Drinking alcohol initially corrects this problem and in- creases serotonin activity, but the person eventually begins to feel worse after tolerance develops.

Drinking gradually becomes heavier and more frequent. The person becomes tolerant to the effects of alcohol and must drink larger quantities to achieve the same reinforcing effects. After he or she becomes addicted to alcohol, attempts to quit drinking are accompanied by painful withdrawal symptoms. Prolonged abuse can lead to permanent neurological impairment, as well as the disruption of many other organ systems.

Treatment The treatment of alcoholism and other types of substance use disorders is an especially difficult task. Many people with sub- stance use disorders do not acknowledge their difficulties, and

substance-related and addictive disorders CHAPTER 11 309

in many other parts of the world, AA is generally considered to be “the first line of attack against alcoholism” (Nathan, 1993). Many members of AA are also involved in other forms of treat- ment offered by various types of mental health professionals, but AA is not officially associated with any other form of treatment or professional organization. Similar self-help programs have been developed for people who are dependent on other drugs, such as opioids (Narcotics Anonymous) and cocaine (Cocaine Anonymous).

The viewpoint espoused by AA is fundamentally spiritual in nature (Kaskutas et al., 2003). AA is the original 12-step program. In the first step, the person must acknowledge that he or she is powerless over alcohol and unable to manage his or her drinking. The remaining steps involve spiritual and in- terpersonal matters such as accepting “a Power greater than ourselves” that can provide the person with direction; recog- nizing and accepting personal weaknesses; and making amends for previous errors, especially instances in which the person’s drinking caused hardships for other people. One principal as- sumption is that people cannot recover on their own (Emrick, 1999).

The process of working through the 12 steps to recovery is facilitated by regular attendance at AA meetings, as often as ev- ery day of the first 90 days after the person stops drinking. Most people choose to attend less frequently if they are able to remain sober throughout this initial period. Meetings provide chronic al- cohol abusers with an opportunity to meet and talk with other people who have similar problems, as well as something to do instead of having a drink. New members are encouraged to call more experienced members for help at any time if they experi- ence an urge to drink. There is enormous variability in the format and membership of local AA meetings (Montgomery, Miller, & Tonigan, 1993).

It is difficult to evaluate the effectiveness of AA, for a num- ber of reasons. Long-term follow-up is difficult, and it is gener- ally impossible to employ some of the traditional methods of

Disulfiram (Antabuse) is a drug that can block the chemi- cal breakdown of alcohol. It was introduced as a treatment for alcoholism in Europe in 1948 and is still used fairly extensively (Fuller & Gordis, 2004). If a person who is taking disulfiram consumes even a small amount of alcohol, he or she will become violently ill. The symptoms include nausea, vomiting, profuse sweating, and increased heart rate and respiration rate. People who are taking disulfiram will stop drinking alcohol in order to avoid this extremely unpleasant reaction. Unfortunately, volun- tary compliance with this form of treatment is poor. Many pa- tients discontinue taking disulfiram, usually because they want to resume drinking or because they believe that they can man- age their problems without the drug.

Naltrexone (Revia) is an antagonist of endogenous opioids that has been found to be useful in the treatment of alcohol de- pendence following detoxification. Research studies have demon- strated that patients who received naltrexone and psychotherapy are less likely to relapse than patients who receive psychotherapy plus a placebo (Carmen et al., 2004). Some clinical patients re- port that, if they drink while also taking naltrexone, they do not feel as “high” as they would without naltrexone. Naltrexone may dampen the person’s craving by blocking alcohol’s ability to stim- ulate the opioid system. In other words, it works by reducing the rewarding effects of alcohol rather than by inducing illness if the person drinks.

Another promising medication for treating alcoholism is acamprosate (Campral). An extensive body of evidence indicates that people taking acamprosate are able to reduce their average number of drinking days by 30 percent to 50 percent (Mann, Lehert, & Morgan, 2004). It also increases the proportion of peo- ple who are able to achieve total abstinence (approximately 22 percent among people taking acamprosate and 12 percent taking placebo after 12 months of treatment). Like naltrexone, acampro- sate is intended to be used in conjunction with a psychological treatment program. The dropout rate is very high without these added features (Hart, McCance-Katz, & Kosten, 2001; Malcolm, 2003).

Psychiatrists also use SSRIs, such as fluoxetine, for the long- term treatment of alcoholic patients. Outcome studies suggest that SSRIs have small and inconsistent effects in reducing drink- ing among those patients who are not also depressed. They do seem to be effective, however, for the treatment of people with a dual diagnosis of alcohol dependence and major depression (O’Brien & McKay, 2002).

Self-help groups: Alcoholics Anonymous One of the most widely accepted forms of treatment for alco- holism is Alcoholics Anonymous (AA). Organized in 1935, this self-help program is maintained by alcohol abusers for the sole purpose of helping other people who abuse alcohol become and remain sober. Because it is established and active in virtu- ally all communities in North America and Europe, as well as

Group therapy is an important part of most inpatient treatment pro- grams. It offers an opportunity for patients to acknowledge and confront openly the severity of their problems.

310 CHAPTER 11 substance-related and addictive disorders

associated with impulsive behavior, such as bulimia and inappropri- ate sexual behaviors (see Chapters 10 and 12). It places principal emphasis on events that take place after detoxification and is aimed at helping the addict to deal with the challenges of life without drugs. The therapist helps patients learn more adaptive coping re- sponses, such as applied relaxation and social skills, that can be used in situations that formerly might have triggered drug use.

One important feature of the relapse prevention model is concerned with the abstinence violation effect, which refers to the guilt and perceived loss of control that the person feels whenever he or she slips and finds himself or herself having a drink (or a cigarette or whatever drug is involved) after an extended period of abstinence. People typically blame themselves for failing to live up to their promise to quit. They also interpret the first drink or use of the drug as a signal that further efforts to control their drinking will be useless. The following brief case study describes one man’s thoughts and feelings, shortly after he returned to the use of heroin. Just prior to this relapse, he had been actively in- volved in a treatment program and had stayed “clean” for several months.

Relapse to Heroin Use It was like goin’ home,” he tells me later, “and mom’s got your favorite dish on the stove, and you smell it, to the back of your tongue, way back. That’s the rush of the dope. It’s right there, and for like two, three minutes I’m floating. I get up and lay down in my bed, put on the (music) again.”

He slams his fist on his knee. “I can’t believe how bad I (screwed) up,” Mike wails through his tears. “Damn! I know what happened ain’t nobody’s fault but mine, and I’m eating myself up over it. I’m scared out of my mind. I mean, it’s like I’m afraid of myself. So where do I go with that if they kick me out? How do I stay off the dope if I’m alone again?”

outcome research, such as random assignment to groups and pla- cebo controls. Early dropout rates are relatively high: About half of all the people who initially join AA leave in less than three months. On the other hand, survival rates (defined in terms of continued sobriety) are much higher for those people who remain in AA. About 80 percent of AA members who have remained so- ber for between two and five years will remain sober in the next year (Tonigan, Connors, & Miller, 2003).

cognitive Behavior therapy Psychological approaches to substance use disorders have often focused on cognitive and behavioral responses that trigger epi- sodes of drug abuse. In the case of alcoholism, heavy drinking has been viewed as a learned, maladaptive response that some people use to cope with difficult problems or to reduce anxiety. Cog- nitive behavior therapy teaches people to identify and respond more appropriately to circumstances that regularly precipitate drug abuse (Finney & Moos, 2002).

coPIng SkILLS trAInIng One element of cognitive behav- ior therapy involves training in the use of social skills, which might be used to resist pressures to drink heavily. It also in- cludes problem-solving procedures, which can help the person both to identify situations that lead to heavy drinking and to formulate alternative courses of action. Anger management is one example. Some people drink in response to frustration. Through careful instruction and practice, people can learn to express negative emotions in constructive ways that will be un- derstood by others. The focus in this type of treatment is on factors that initiate and maintain problem drinking rather than the act of drinking itself.

Cognitive events also play an important part in this ap- proach to treatment. Expectations about the effects of alcohol are challenged, and more adaptive thoughts are rehearsed. Negative patterns of thinking about the self and events in the person’s envi- ronment are also addressed because they are linked to unpleasant emotions that trigger problem drinking.

reLAPSe PreventIon Most people who have been addicted to a drug will say that quitting is the easy part of treatment. The more difficult challenge is to maintain this change after it has been accomplished. Unfortunately, most people will slip up and return to drinking soon after they stop. The same thing can be said for people who stop smoking or using any other drug of abuse. These slips often lead to a full-scale return to excessive and uncontrolled use of the drug. Successful treatment, therefore, depends on making preparations for such incidents.

Relapse prevention is a cognitive behavioral approach to treat- ment view that has been applied to all forms of substance use disorder, ranging from alcoholism to nicotine addiction (Mar- latt, Blume, & Parks, 2001; Shiffman et al., 1996; Witkiewitz, Marlatt, & Walker, 2005). It has also been applied to other disorders

MyPsychLab Video Case

Compulsive Gambling

Ed

“My mother was on her deathbed. Her words to me were, ‘You’ve got to stop gambling. It’s ruining your life. You’ll lose everything.’ She died the following day, and I spent the next year of my life prov- ing her right. I did lose everything.”

Watch the Video Ed: Gambling Disorder on MyPsychLab

As you watch the interview and the day-in-the-life segments, ask yourself what purpose Ed’s gambling seemed to play in his life. How was his preoccupation with gambling different from a serious commitment to a career or a hobby?

substance-related and addictive disorders CHAPTER 11 311

outcome results and general conclusions Although many studies have evaluated the effects of alcohol treat- ment programs, two deserve special attention because of their large sample sizes and the rigorous methods that the investigators employed. One is known as Project MATCH because it was de- signed to test the potential value of matching certain kinds of cli- ents to specific forms of treatment (Babor & Del Boca, 2003). In other words, would the outcomes associated with different forms of intervention be related to certain characteristics of the patients (such as the presence or absence of antisocial personality traits)?

The study evaluated three forms of psychological treatment: cognitive behavior therapy (12 sessions focused on coping skills and relapse prevention), 12-step facilitation therapy (12 sessions designed to help patients become engaged in AA), and moti- vational enhancement therapy (four sessions over 12 weeks de- signed to increase commitment to change). Most of the people in all three groups attended at least some AA meetings in addition to their assigned form of treatment. More than 1,700 patients were randomly assigned to one of these three conditions. Outcome measures were collected for three years after the end of treatment.

Results indicated that all three forms of treatment led to major improvements in amount of drinking as well as other areas of life functioning (Miller & Longabaugh, 2003). Before treatment, pa- tients in this study averaged 25 drinking days per month. After treat- ment, they averaged fewer than six days per month (across all forms of treatment). Very few differences were found between the different treatment methods. The one exception favored 12-step facilitation therapy, in which 24 percent of patients were completely abstinent one year after treatment, compared to approximately 15 percent in the other two groups. Analyses that focused on the characteristics of individual clients suggested that there is relatively little reason to try to match certain kinds of patients to specific forms of treatment.

The second study involved a naturalistic evaluation of sub- stance abuse treatment programs administered at 15 sites by the De- partment of Veterans Affairs (VA) (Finney, Moos, & Humphreys, 1999; Moos et al., 1999). The VA study compared programs that emphasized three approaches to the treatment of substance use dis- orders: 12-step programs, cognitive behavior therapy, and “eclectic therapy” (a combination of several approaches). The study included more than 3,000 patients. Most of these people had a diagnosis of alcohol dependence, but many also abused other types of drugs. Unlike Project MATCH, they were not randomly assigned to treat- ments. Despite these differences in methodology, results of the VA study were very similar to those obtained in Project MATCH. Patients in all three groups made significant improvements with regard to both patterns of substance use and levels of social and occupational functioning. People who participated in more treat- ment sessions had better outcomes than people who received less treatment. When differences were found between different forms of treatment, they tended to favor the 12-step programs. No sup- port was found for the assumption that certain types of patients would do better in one form of treatment than in another.

Mike looks up, his eyes wide, wet with tears. “Maybe what they say is true, I’m already a junkie again. It’s

too late. But I did just one hit, that’s all. And I can’t be doing more dope, I know that. If I go on a real run of heroin this time, I won’t come back, ever. I’ve seen it now—I can blow it, I can relapse, I can die. Damn! This is the time I need help more than ever, and this is when they’re going to kick me out” (Shavelson, 2001, pp. 161 and 166)

Relapse prevention programs are aimed at exactly this type of conflict. They teach patients to expect that they may slip oc- casionally and to interpret these behaviors as a temporary “lapse” rather than a total “relapse.”

Short-term motIvAtIonAL therAPY Many people with substance use disorders do not seek or take full advantage of treatment opportunities because they fail to recognize the sever- ity of their problems. Motivational interviewing is a nonconfron- tational procedure that can be used to help people resolve their ambivalence about using drugs and make a definite commitment to change their behavior (Miller, 1995). It is based on the notion that in order to make a meaningful change, people must begin by recognizing the inconsistency between their current behavior and their long-term goals. For example, chronic heavy drinking is not compatible with academic or occupational success.

Motivational interviewing begins with a discussion of problems—issues reported by the patient as well as concerns that have been expressed by others such as friends and fam- ily members. The person is asked to reflect on feedback that is provided in a nonthreatening way. Rather than confronting the person, arguing about the reasons for drinking, or demanding action, the therapist responds empathically in an effort to avoid or minimize defensive reactions that will interfere with attempts to change.

The primary goal of this process is to increase the person’s awareness of the nature of his or her substance use problems. Central features of motivational interviewing include a com- prehensive assessment of the situation and personalized feed- back. Emphasis is placed on ways in which the person sees his or her problems rather than assigning diagnostic labels, such as “alcoholism.” Various options for creating change are discussed. The therapist and the patient work together to select the most appropriate method to follow. This stage of the interaction is designed to encourage the person’s belief in his or her own ability to accomplish positive change.

Motivational interviewing may be most helpful to people whose substance abuse problems are not yet severe or chronic. It can be used as a stand-alone intervention or in combination with other approaches to treatment. If the person is not ready to abstain completely, short-term motivational therapy can be used to help the person reduce the frequency or intensity of alcohol consumption (Roberts & Marlatt, 1999).

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treatment are usually not limited to drug use alone but ex- tend to the person’s health in general as well as his or her social and occupational functioning. Long-term outcome for the treatment of alcoholism is best

predicted by the person’s coping resources (social skills and prob- lem-solving abilities), the availability of social support, and the level of stress in the environment. These considerations appear to be more important than the specific type of intervention that people receive. Those individuals who are in less stressful life situations, whose families are more cohesive and less supportive of continued drinking, and who are themselves better equipped with active coping skills are most likely to sustain their improve- ment over several years.

Gambling Disorder While no one doubts that pathological gambling can be an ex- tremely debilitating condition, the classification of this disorder has been somewhat confusing and inconsistent. In DSM-IV, it was included with impulse control disorders. The authors of DSM-5 moved it to the chapter on substance-related and addictive disorders (see Thinking Critically about DSM-5) based in part on the obser- vation that people with serious gambling problems frequently suffer from various substance use disorders as well (Lorains, Cowlishaw, Thomas, 2011; Milosevic & Ledgerwood, 2010). Some of the

Comprehensive reviews of these studies and the rest of the research literature regarding treatment of alcoholism and drug abuse point to several general conclusions (Amato et al., 2011; Glasner-Edwards & Rawson, 2010):

• People who enter treatment for various types of substance abuse and dependence typically show improvement in terms of reduced drug use that is likely to persist for several months following the end of treatment. Unfortunately, relapse is also relatively common.

• There is little evidence to suggest that one form of treat- ment (inpatient or outpatient, professional or self-help, individual or group) is more effective than another. When differences have been found, they tend to favor self-help groups, such as AA, particularly in terms of success in achieving abstinence.

• There is only limited support for the assumption that certain kinds of patients do better in one kind of treatment than an- other (the matching hypothesis).

• Increased amount of treatment and greater frequency of at- tendance in self-help meetings and aftercare counseling are associated with better outcomes.

• Among those people who are able to reduce their consump- tion of drugs, or abstain altogether, improvements following

Thinking CriTiCaLLy about dsM-5

Is Pathological Gambling an Addiction?

Many forms of psychopathology entail excessive be-haviors. The persistent, harmful use of drugs is one obvious example. Mental health professionals are also concerned about an even more heterogeneous class of problems that is defined by excessive behaviors, ranging from binge eat- ing (see Chapter 10) to hoarding and hair-pulling (see Chapter 6) and pathological gambling. At various times, all of these prob- lems have been described informally as behavioral addictions. That terminology became official in DSM-5, where pathological gambling is now listed in the chapter on “Substance-Related and Addictive Disorders.” This is an important and controversial development. The fact that one type of behavioral addiction ap- pears in DSM-5 will almost certainly open the door for the inclu- sion of others as the manual is revised. Serious consideration has already been given to excessive Internet gaming, sexual behavior, shopping, and exercise as possible forms of mental disorder. Should this expansion of the diagnostic manual be welcomed or encouraged? We think not, for several important reasons (Petry, 2006; Stein, 2008; Wilson, 2010).

One issue should be obvious. Substance use disorders involve re- peated exposure of the brain to toxic chemicals, and behavioral

addictions do not. Substance use disorders frequently involve physiological mechanisms known as tolerance and withdrawal. It is less clear that these effects play an important role in the progression of pathological gambling and other behavioral ad- dictions. Over the course of time, chronic abuse of drugs must surely involve some unique problems that will distinguish sub- stance use disorders from other forms of excessive behavior.

Second, it is important to be careful about the meaning of spe- cific terms in describing symptoms of psychopathology. Lump- ing these problems together may have the opposite effect. Some clinicians refer to compulsive gambling. Others talk about gambling addiction. And the previous version of the diagnostic manual listed pathological gambling as a type of impulse con- trol disorder. These terms have all become part of our every- day language, and the vague ways in which they are used can make it hard for us to think precisely about the nature of these problems. All of the terms imply a generic loss of control over behavior as well as some kind of failure to anticipate or avoid the negative consequences of self-damaging behaviors. But the mechanisms that presumably maintain the problem behavior vary from one concept to the next. Compulsions are repetitive

substance-related and addictive disorders CHAPTER 11 313

refers to the process of trying to win back money that has already been lost. Many people who gamble socially begin by setting a fi- nancial limit for themselves; if they lose that money, they quit. In pathological gambling, people frequently follow initial losses by betting even greater amounts of money (while telling themselves and others that they will quit as soon as they win big). Need- less to say, this process is almost always futile and results in even greater losses.

Experiences that are similar to tolerance and withdrawal have been reported among people with serious gambling prob- lems. Some report, for example, that they felt compelled to gamble with increased stakes in order to achieve the same emo- tional effects. It is important to note, however, that chasing losses could be somewhat difficult to distinguish from toler- ance effects.

Investigators have also reported that withdrawal-like symp- toms are sometimes experienced by people when they try to stop or cut back on their gambling. Approximately half of the people in one study reported a range of emotional consequences,

symptoms of gambling disorder are also shared with problems such as alcoholism, including preoccupation with activities related to gambling and frequent, unsuccessful attempts to quit.

Most gambling is not associated with a mental disorder. So- cial gambling is a form of recreation that is accepted in most cul- tures. Professional gambling is an occupation pursued by people whose gambling is highly disciplined. Pathological gambling, in contrast, is out of control, takes over the person’s life, and leads to horrendous financial and interpersonal consequences.

Symptoms Like various kinds of substance use disorders, the central fea- tures of gambling disorder center around impaired control of gambling activities, social impairment that follows from gambling (such as loss of jobs or relationships), and contin- ued problem behavior in spite of the accumulation of harmful consequences.

One feature that is unique to gambling disorder, in compari- son to substance use disorders, is chasing losses. This expression

behaviors that serve to reduce anxiety (typically anxiety caused by obsessions). Impulsive behaviors, on the other hand, typi- cally imply failure to resist temptation to engage in a behavior that is pleasurable, such as eating or having sex. Compulsive behaviors are not associated with pleasure. Addictions are often performed in an effort to relieve signs of withdrawal, which are typically unpleasant physiological symptoms. It is not clear that behavioral addictions are associated with physiological symp- toms of withdrawal. Using these terms as if they are interchange- able can lead to confusion.

You may be asking yourself, “What difference does it make?” At this stage of our science, these models imply different ways

to study this set of problems as well as different avenues for treatment. The rationale presented in DSM-5 for the inclusion of gambling disorder with substance use disorders is that these behaviors all activate reward pathways in the brain (see Figure 11.7). That’s obviously an important consideration, but it’s also premature to assume that our understanding of neural reward pathways provides a complete or precise guide to the nature of these problems.

Perhaps more to the point, the term “addiction” implies an absence of responsibility for one’s behavior. This makes sense in the case of chemical addictions, although some would not call alcohol and drug abuse addictions for this reason. One persuasive argument suggests that alcoholism is best viewed as a central activity, in other words, a set of interests and patterns of behavior that motivate the person’s identity, behavior, and life choices. “Heavy drinkers are people who have over time made a long and complex series of decisions, judgments, and choices of commission and omission that have coalesced into a central activity. . . . Instead of viewing heavy drinkers as the helpless victims of a disease, we come to see their drinking as a meaningful, however destructive, part of their struggle to live their lives (Fingarette, 1988, pp. 102–103).

Gambling, eating, sex, shopping, and many other behaviors surely are problematic when taken to extremes. Does this make them addictions? Are some people truly not responsible for these actions? We think this is a philosophical question more than a scientific one, a decision that is better made by law and society than by the DSM (Young, 2013). Yet, our real question is: What do you think?

Source: Ronald Markowitz/The New Yorker Collection/www.cartoonbank.com

314 CHAPTER 11 substance-related and addictive disorders

Diagnosis DSM-5 includes nine features in its definition of gambling disor- der, and the person must exhibit at least four of them in order to meet the threshold for a diagnosis. Five of these symptoms bear a strong resemblance to diagnostic criteria for alcohol use disorder (compare with “DSM-5: Alcohol Use Disorder”): gambling with increasingly larger amounts of money to experience the same level of stimulation (similar to tolerance); becoming agitated or easily annoyed when trying to stop gambling (similar to with- drawal); repeated failed efforts to quit gambling; preoccupation with gambling; and impaired social or occupational functioning as a result of gambling. The other diagnostic criteria for gambling disorder are less similar to criteria for alcohol use disorder. They are: chasing losses; frequent gambling when experiencing emo- tional distress; lying to other people in order to cover up the ex- tent of gambling; and depending on financial help from others to cope with losses from gambling.

There are two noteworthy differences between this defini- tion and the definition of gambling disorder that appeared in the previous version of the manual (DSM-IV). First, one di- agnostic criterion—illegal acts—was dropped from the previ- ous list. That feature stipulated that the person “has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling.” Research studies demonstrated that the ille- gal acts criterion was rarely endorsed, was only associated with the most severe cases, and was not useful in distinguishing be- tween people who do and who do not seek treatment for gam- bling disorder (Denis, Fatséas, Auriacombe, 2012). Second, the threshold for a diagnosis was dropped from five features to four. Empirical data support the validity of this change (Petry et al., 2012).

frequency Evidence regarding the frequency of various levels of gam- bling problems has become increasingly available in recent years (Black, McCormick, Losch, Shaw, Lutz, Allen, 2012). Of course, these estimates vary as a function of several important factors, including the methods used to collect the data (inter- views versus questionnaires), the definitions that were employed to identify gambling problems, the age of the people who were surveyed, and the country in which the data were collected (including the availability and legal status of various gambling options).

The lifetime prevalence of pathological gambling in the United States and European countries is approximately 2 percent of the population and may be increasing with the spread of legal- ized gambling (Sassen, Kraus, & Buhringer, 2011; Welte, Barnes, Tidwell, Hoffman, 2008). Men are more likely than women to become pathological gamblers.

including restlessness and irritability as well as feelings of an- ger, guilt, and depression (Cunningham-Williams et al., 2009). It remains to be seen whether the analogy with symptoms of alcohol withdrawal is useful. The latter include physiological symptoms (sweating, increased heart rate, hand tremor), nausea and vomiting, and transient hallucinations. The similarity be- tween symptoms of gambling disorder and substance use disor- ders is strongest with regard to loss of control of behavior and weakest with regard to the possible development of physiological aspects of tolerance and withdrawal.

People who suffer from gambling disorder tend to be intel- ligent, well-educated, competitive people who enjoy the chal- lenges and risks involved in betting. The following brief case study describes one highly publicized example of the enormous personal costs that can be associated with a serious gambling problem.

Art Schlichter’s Gambling Disorder The tragic life of Art Schlichter provides a vivid illustration of the devastating impact that persistent, uncontrolled gambling can have on a person and his family (Keteyian, 1986; Valente, 1996). Schlichter, an All-American quarterback at Ohio State University, was the first player drafted by the National Football League in 1982. He had been gambling since high school, but the prob- lem became worse after he started playing professional football. His career was disappointing. As the pressures mounted, so did his gambling debts, which eventually reached $1 million. He was cut from several teams in the National Football League and the Canadian Football League and was ultimately banned from the NFL for betting on professional games. He entered treatment for his compulsive gambling on several occasions, but the re- sults were unsuccessful and his repeated promises to stop gam- bling went unfulfilled. Schlichter’s promising football career was ruined, and his young family was torn apart by his uncontrolled gambling.

Schlichter has been arrested and jailed on several occa- sions for charges that include forgery, theft, and bank fraud. In 2001, he was sentenced to six years in prison for violat- ing the terms of his probation. Sadly, his problems continued unabated following his release from prison in 2006, in spite of the fact that he founded a non-profit organization for the purpose of teaching others about pathological gambling. In 2010, he was sentenced to another 10 years in prison after being convicted of participating in a million-dollar ticket scam. The court decided to increase the length of his prison term after learning that he tested positive for use of cocaine while he was under house arrest while the most recent case was be- ing investigated.

substance-related and addictive disorders CHAPTER 11 315

getting heLP

If you have been looking for help in the area of substance dependence, you have probably noticed two things: (1) There are so many different sources of advice and information that the situation can quickly become quite confusing, and (2) the field is sharply divided on a number of crucial issues. Whose ad- vice should you follow? Among all of the self-help books dealing with drugs and alcohol, one stands out on the basis of its strong link to the research literature as well as the extensive clinical ex- perience of the author. Marc Schuckit’s book Educating Yourself About Alcohol and Drugs: A People’s Primer provides sensible answers to the questions asked by people who are wondering about their own, or someone else’s, substance use problems.

Denial is a prominent feature of most substance use disorders. It is usually easier to dismiss suggestions that you have begun to use alcohol or drugs in a self-destructive pattern than it is to face the problem directly. Schuckit’s book includes a perceptive chapter titled “Is there really a problem?” The bottom line is this: “If you repeatedly have returned to substance use even though that substance has caused a disruption in your life, you do have a problem.” Subsequent chapters in Schuckit’s book provide thoughtful and practical guidance on topics such as the symp- toms of withdrawal, the process of detoxification, the relative merits of self-help groups, outpatient therapy, and hospitaliza- tion, and how to find a specific treatment program in your area.

The Internet also provides an enormous amount of information regarding substance use disorders. For information about prob- lems associated with the use of alcohol and drugs, you might want to visit Web pages maintained by the National Institute on Alcohol Abuse and Alcoholism (www.niaaa.nih.gov) and the

National Institute on Drug Abuse (www.nida.nih.gov). These Web sites are primarily concerned with information about feder- ally funded research programs, but they also include answers to frequently asked questions, as well as treatment referral information.

Most people who enter treatment for substance use problems become involved, at least temporarily, with self-help groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Related groups, like Alanon and Alateen, are designed for the families and children of people who are dependent on alcohol. You can contact these groups through the Internet. The URL for Alcoholics Anonymous is www.alcoholics-anonymous.org. Many people believe, often passionately, that AA is the most ben- eficial program for helping people to recover from alcoholism. Others disagree. If you want to consider alternative points of view, visit the Web site maintained by Stanton Peele, who is one of AA’s most persistent, enthusiastic, and articulate critics. The URL for his homepage is www.peele.net. Peele challenges the biological reductionism that often dominates current views of alcoholism, and he promotes approaches to treatment that do not rely exclusively on total abstinence from drinking.

Evidence regarding the long-term outcome of serious substance use disorders can be discouraging, but it is important to remem- ber that a substantial minority of people with these problems do manage to achieve an extended, stable recovery. The research literature does not point to one form of treatment as being clearly superior to another. Therefore, you should consider sev- eral alternatives to treatment and select the one that makes most sense in terms of your own life and your own view of the world.

A drug of abuse—sometimes called a psychoactive substance— is a chemical substance that alters a person’s mood, level of perception, or brain functioning. Although patterns of substance use disorder are similar in some ways for all drugs, each type of drug also has some unique features.

Two particularly important features of substance use disorders are known as tolerance and withdrawal. Tolerance refers to the process

through which the nervous system becomes less sensitive to the effects of alcohol or any other drug of abuse. Withdrawal refers to the symptoms experienced when a person stops using a drug.

Prolonged abuse of alcohol and other drugs of abuse can have a devastating impact on social relationships and occu- pational functioning while disrupting the functions of several important organ systems. Alcohol use disorder has more negative health consequences than does abuse of almost any drug, with the possible exception of nicotine.

nicotine is one of the most harmful addicting drugs. Recognizing the serious long-term health consequences of exposure to nicotine, the U.S. Food and Drug Administration has prohibited the sale and distribution of tobacco products to children and adolescents. This policy attempts to prevent the development of nicotine addiction rather than trying to ban use of the drug completely.

summary11

316 CHAPTER 11 substance-related and addictive disorders

The psychomotor stimulants, such as amphetamine and cocaine, activate the sympathetic nervous system and induce a positive mood state. High doses of amphetamines and cocaine can lead to the onset of psychosis.

opiates have properties similar to those of opium and can induce a state of dreamlike euphoria. Tolerance develops quickly to opiates. After repeated use, their positive emotional effects are replaced by long-term negative changes in mood and emotion.

Sedatives, hypnotics, and Anxiolytics can be used, as pre- scribed by a physician, to decrease anxiety (tranquilizers) or help people sleep (hypnotics). People who abruptly stop taking high doses of these drugs may experience withdrawal symptoms, including a return of anxiety symptoms.

marijuana and hashish can induce a pervasive sense of well-being and happiness. People do not seem to develop tolerance to THC (the active ingredient in marijuana and hashish) unless they are exposed to high doses over an extended period of time.

hallucinogens induce vivid visual images that are usually pleas- ant but occasionally frightening. Unlike other drugs of abuse, hallucinogens are used sporadically rather than continuously. Most people do not increase their use of hallucinogens over time, and withdrawal symptoms are not observed.

DSM-5 defines alcohol use disorder in terms of a set of 11 fea- tures that include signs of impaired control over use of alcohol, social impairment resulting from chronic drinking, risk use of alcohol, and pharmacological criteria. The person has to exhibit at least two of these criteria within a 12-month period of time for a diagnosis of alcohol use disorder to be made. The severity of the disorder is also noted, based on the number of symptoms that are present: mild (2–3 symptoms), moderate (4–5 symp- toms), or severe (6 or more symptoms).

Alcohol use disorder is one of the most common forms of mental disorder, with a lifetime prevalence of 30 percent in the NESARC study. Among people with alcohol use disorders, men outnumber women by a ratio of approximately two to one.

Research on the causes of alcoholism illustrates the ways in which various systems interact to produce and maintain drug dependence. There are several pathways to alcoholism. Social factors are particularly influential in the early phases of sub- stance use. The culture in which a person lives influences the types of drugs that are used, the purposes for which they are used, and the expectations that people hold for the ways in which drugs will affect their experiences and behavior.

Twin studies indicate that genetic factors influence patterns of social drinking as well as the onset of alcohol use disorder. Adoption stud- ies indicate that the offspring of alcoholic parents who are raised by nonalcoholic parents are more likely than people in the general population to develop drinking problems of their own.

All of the psychoactive drugs cause increased dopamine activity in the reward pathways of the brain. Alcohol may stimulate the mesolimbic dopamine pathway directly, or it may act indirectly by inhibiting GABA neurons. Another focus of neurochemical research has been the role of endogenous opioids known as endorphins. Some theorists have argued that alcoholism is associated with excessive production of endorphins.

Expectations about drug effects have an important influence on the ways in which people respond to alcohol and other drugs. People who believe that alcohol enhances pleasure, reduces ten- sion, and increases social performance are more likely than other people to drink frequently and heavily.

Treatment of substance use disorders is an especially challenging and difficult task, in light of the fact that many people with these problems do not recognize or acknowledge their own difficulties. Recovery begins with a process of detoxification. Self-help pro- grams, such as Alcoholics Anonymous, are the most widely used and probably one of the most beneficial forms of treatment.

Defining features of gambling disorder include impaired con- trol of gambling activities, social impairment that follows from gambling (such as loss of jobs or relationships), and continued problem behavior in spite of the accumulation of harmful con- sequences. One feature that is unique to gambling disorder, in comparison to substance use disorders, is chasing losses.

11.1 What evidence is needed to show that a drug is addictive? If repeated use of a drug is associated with the development of toler- ance and withdrawal, or if it leads to a pathological pattern of use, then it is considered to be addictive . . . (see pages 287–288).

11.2 What are the long-term consequences of abusing psycho- motor stimulants? Prolonged use of amphetamines and cocaine increases the person’s risk for having a psychotic episode, but the most common and devastating

effects of stimulant drugs are the serious disruption of occupational and social roles . . . (see page 291).

11.3 Where is the boundary between substance use disorders and recreational drug use? The transition from recreational use to the onset of a disorder can be subtle and is not easily recognized, especially by the person who is using drugs. The distinction hinges on the pattern of use, which must be persistent over time and lead to maladaptive consequences before this diagnosis would be considered . . . (see page 296).

critical thinking review

The Big Picture

substance-related and addictive disorders CHAPTER 11 317

key terms alcohol use disorder 296 barbiturates 293 benzodiazepines 293 detoxification 308

endorphins 306 hallucinogens 294 hashish 294 high-risk research design 307

marijuana 294 opiates 292 psychomotor stimulants 291 substance use disorder 285

tolerance 288 withdrawal 288

11.4 In what ways are drug problems different among the elderly? Tolerance to many drugs is reduced among the elderly, and the symptoms of withdrawal may be more severe and prolonged . . . (see pages 301–302).

11.5 What are the most important risk factors for alcoholism? Increased risk is associated with both genetic and environmental fac- tors. Some of the genes that influence risk of alcohol dependence have an impact on the metabolism of alcohol. Others may influence personality traits which increase the tendency to participate in dan- gerous patterns of consumption . . . (see pages 307–308).

11.6 How does AA differ from other approaches to treating alcoholism? Alcoholics Anonymous is a self-help program and is not officially associated with any other form of treatment. Its viewpoint is funda- mentally spiritual in nature . . . (see page 309).

11.7 What factors predict better long-term outcome for treat- ment of alcoholism? Long-term outcome is best predicted by the person’s coping resources (social skills and problem-solving abilities), the availability of social sup- port, and the level of stress in the environment . . . (see pages 311–312).

Virtual Case Studies

Virtual Case Studies offer you a science-based, interactive simulation where you can learn how a number of risk factors and protective factors could impact disorder development in a virtual person. As you progress through the simulation you will not act as the character or as a clinician, but will be able to independently explore a variety of different behaviors, events, and outcomes that one who suffers from a disorder could potentially encounter. You can access the Virtual Case Study on Substance Abuse Disorders at mypsychlab.com.

sexual dysfunctions, paraphilic disorders, and gender dysphoria

12

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 319

Sex is often a perplexing area of our lives. Sexual experience can be a source of extreme pleasure, while also providing for the de- velopment and expression of intimacy with one’s partner. From an evolutionary point of view, reproduction is the key to our survival. Sexual behavior also provides fertile ground for intense feelings of fear and guilt.

When something interferes with our ability to function sexu- ally, it can be devastating both to the person who is affected and to the person’s partner. Sometimes a person’s inability to enjoy sexual experiences becomes so pervasive or so personally distressing that the person seeks professional help—alone or, more often, with his or her partner. In other instances, a person may enjoy sex but his or her sexual interest may be triggered by unusual stimuli, or it may involve nonconsenting partners or the pain and suffering of the self or others. The point at which occasional sexual difficulties become a “sexual dysfunction” is quite subjective and may say as much about sexual norms and expectations as anything else. Simi- larly, the definition of sexual conduct that is considered deviant has also changed over time. This chapter explores the mix of fac- tors that influence what it means to be a man or a woman and the ways in which we engage in sexual relationships. It also offers a

The Big Picture learning objectives

12.1 Should sexual problems be defined primarily

in terms of difficulty reaching orgasm?

12.2 What role to mental scripts play in sexual arousal?

12.3 What are the primary targets of psychological approaches to treating sexual dysfunctions?

12.4 How have changing attitudes toward sexuality

influenced the definition of paraphilias?

12.5 Should excessive sexual behavior be

considered a disorder in its own right?

12.6 Does deviant sexual arousal ever play a role

in sexual assaults?

picture of the shifting ground that surrounds what mental health professionals consider to be normal and abnormal sexual practices.

Overview Any discussion of sexual disorders requires some frank consid- eration of normal sexuality. Such openness has been encouraged and promoted by mental health professionals who specialize in the study and treatment of sexual behavior.

William Masters (1915–2001) and Virginia Johnson (1925–2013) were undoubtedly the best-known sex therapists and researchers in the United States during the second half of the twentieth cen- tury. Their first book, Human Sexual Response, published in 1966, was based on their studies of nearly 700 normal men and women. Observations and physiological recordings were made in a laboratory setting while these individuals engaged in sexual activities, including masturbation and intercourse. Masters and Johnson’s research re- ceived widespread attention in the popular media and helped make laboratory studies of sexual behavior acceptable ( Maier, 2009).

On the basis of their data, Masters and Johnson described the human sexual response cycle in terms of a sequence of overlapping phases: excitement, orgasm, and resolution. Analogous processes occur in both men and women, but the timing may differ. Many of the physiological mechanisms involved in this cycle are now understood more clearly, and progression from one phase to the next is not always strictly linear, but the general outline described by Masters and Johnson is still useful (Hayes, 2011; Levin, 2008). There are, of course, individual differences in virtually all aspects of this cycle. Variations from the most common pattern may not indi- cate a problem unless the person is concerned about the response.

Sexual excitement increases continuously from initial stimu- lation up to the point of orgasm. It may last anywhere from a few minutes to several hours. Among the most dramatic physi- ological changes during sexual excitement are those associated with vasocongestion—engorgement of the blood vessels of various

12

Sexual dysfunctions are best defined in terms of the couple rather than individual persons. They are frequently associated with marital distress.

320 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

relationship was heading downhill, and miscommunication and frustration were growing.

Margaret had two secrets that she had never shared with Bill. Although she found it easier to be orgasmic with manual stimula- tion, she had been orgasmic during intercourse with a married man she’d had an affair with a year before meeting Bill. Margaret expressed ambivalent feelings about that relationship. She felt that the man was a very sophisticated lover, and she had been highly aroused and orgasmic with him. Yet the relationship had been a manipulative one. He’d been emotionally abusive to Mar- garet, and the relationship had ended when he accused Margaret of giving him herpes and berated her. In fact, it was probably he who gave Margaret the herpes. Margaret was only experiencing herpes outbreaks two or three times a year, but when they did oc- cur, she was flooded with negative feelings about herself, sexual- ity, and relationships. She initially saw Bill as a loving, stable man who would help rid her of negative feelings concerning sexuality. Instead, he continually disappointed her with the early ejacula- tion. Bill knew about the herpes but not about her sexual history and strong negative feelings.

Bill was terribly embarrassed about his secret concerning masturbation, which he engaged in on a twice-daily basis. From adolescence on, Bill had used masturbation as his primary means of stress reduction. For him, masturbation was a humiliating secret (he believed married men should not masturbate). The manner in which he masturbated undoubtedly contributed to the early ejac- ulation pattern. Bill focused only on his penis, using rapid strokes with the goal of ejaculating as quickly as he could. This was both to prevent himself from being discovered and from a desire to “get it over with” as soon as he could and forget about it.

When it came to his personal and sexual life, Bill was inhibited, unsure of himself, and had particularly low sexual self- esteem. As an adolescent, Bill remembered being very interested sexually, but very unsure around girls. Bill’s first intercourse at 19 was perceived as a failure because he ejaculated before he could insert his penis in the woman’s vagina. He then tried desperately to insert because the young woman urged him to, but he was in the refractory period (a phenomenon Bill did not understand), and so he did not get a firm erection and felt doubly humiliated (McCarthy, 1989, pp. 151–159).

The case of Bill and Margaret illustrates several important points. First, many sexual problems are best defined in terms of the couple rather than each partner individually. Second, al- though problems in sexual behavior clearly involve basic physi- ological responses and behavioral skills, each person’s thoughts about the meaning of sexual behavior are also extremely impor- tant. Sexual behavior usually takes place in the context of a close, personal relationship. Current views of the sexual response cycle have expanded beyond a simple focus on the mechanisms related to excitement and orgasm (Basson, Brotto, Laan, Redmond, Utian, 2005). They begin at a point of sexual neutrality and

organs, especially the genitals. The male and female genitalia be- come swollen, reddened, and warmed. Sexual excitement also in- creases muscular tension, heart rate, and respiration rate. These physiological responses are accompanied by subjective feelings of arousal, especially at more advanced stages of excitement.

The experience of orgasm is usually distinct from the gradual buildup of sexual excitement that precedes it. This sudden release of tension is almost always experienced as being intensely plea- surable, but the specific nature of the experience varies from one person to the next. The female orgasm occurs in three stages, be- ginning with a “sensation of suspension or stoppage,” which is as- sociated with strong genital sensations. The second stage involves a feeling of warmth spreading throughout the pelvic area. The third stage is characterized by sensations of throbbing or pulsat- ing, which are tied to rhythmic contractions of the vagina, the uterus, and the rectal sphincter muscle.

The male orgasm occurs in two stages, beginning with a sen- sation of ejaculatory inevitability. This is triggered by the move- ment of seminal fluid toward the urethra. In the second stage, regular contractions propel semen through the urethra, and it is expelled through the urinary opening.

During the resolution phase, which may last 30 minutes or longer, the person’s body returns to its resting state. Men are typically unresponsive to further sexual stimulation for a variable period of time after reaching orgasm. This is known as the refrac- tory period. Women, on the other hand, may be able to respond to further stimulation almost immediately. They are capable of experiencing a series of distinct orgasmic responses that are not separated by a period of noticeably lowered excitement.

Sexual dysfunctions can involve a disruption of any stage of the sexual response cycle. The following case study, written by Barry McCarthy, a psychologist at American University, is con- cerned with a man who had difficulty controlling the rate at which he progressed from excitement to orgasm.

Margaret and Bill’s Sexual Communication Margaret and Bill, both in their late twenties, had been married for two years, and they had intercourse frequently. Margaret sel- dom reached orgasm during these experiences, but she was or- gasmic during masturbation. The central feature of their problem was the fact that Bill was unable to delay ejaculation for more than a few seconds after insertion.

Unbeknownst to Margaret, Bill had attempted a “do-it-your- self” technique to gain better control [of ejaculation]. He had bought a desensitizing cream he’d read about in a men’s maga- zine and applied it to the glans of his penis 20 minutes before initi- ating sex. He also masturbated the day before the couple had sex.

During intercourse he tried to keep his leg muscles tense and think about sports as a way of keeping his arousal in check. Bill was unaware that Margaret felt emotionally shut out during the sex. Bill was becoming more sensitized to his arousal cycle and was worrying about erection. He was not achieving better ejaculatory control, and he was enjoying sex less. The sexual

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 321

The incredible diversity of experiences reported by his sub- jects led Kinsey to reject the distinction between normal and abnormal sexual behavior (Robinson, 1976). He argued that dif- ferences among people are quantitative rather than qualitative. For example, Kinsey suggested that the distinction between het- erosexual and homosexual persons was essentially arbitrary and fundamentally meaningless. This argument was later used in sup- port of the decision to drop homosexuality from DSM-III (see Chapter 1) and to cease regarding homosexuality as a form of abnormal behavior. Kinsey’s comments regarding sexual dysfunc- tion reflected a similar view. He believed that low sexual desire was simply a reflection of individual differences in erotic capacity rather than a reflection of psychopathology (Kinsey, Pomeroy, & Martin, 1948).

Sexual Dysfunctions Sexuality represents a complex behavioral process that can easily be upset. Inhibitions of sexual desire and interference with the physiological responses leading to orgasm are called sexual dys- functions. Problems can arise anywhere, from the earliest stages of interest and desire through the climactic release of orgasm. Some people also experience pain during sexual intercourse.

Symptoms How do people evaluate the quality of their sexual relationships? Subjective judgments obviously have an important impact on each person’s commitment to a partnership. Dissatisfaction some- times leads the couple to seek help from a mental health profes- sional. It is useful, therefore, to know something about the ways

consider factors that influence whether the person will seek or be receptive to stimuli that might lead to arousal. They also extend beyond the experience of arousal and orgasm to consider feelings of emotional and physical satisfaction, which ultimately serve to build intimacy.

The classification of sexual disorders was revised dramatically in the United States and Western Europe during the twentieth century. This process reflects important changes in the way that our culture views various aspects of sexual behavior. Before de- scribing the disorders that are included in DSM-5, we outline briefly some of the clinical and scientific perspectives on sexuality that laid the foundation for our current system.

Brief Historical Perspective Over the course of the late twentieth century and into the twenty- first, there has been a trend toward greater tolerance of sexual variation among consenting adult partners and toward increased concern about impairments in sexual performance and experi- ence. Several leading intellectuals influenced public and profes- sional opinions regarding sexual behavior during the first half of the twentieth century. The work of Alfred Kinsey (1894–1956), a biologist at Indiana University, was especially significant. In keep- ing with his adherence to scientific methods, Kinsey adopted a behavioral stance, focusing specifically on those experiences that resulted in orgasm. In their efforts to describe human sexual be- havior, Kinsey and his colleagues interviewed 18,000 men and women between 1938 and 1956 (Jones, 1997). They asked each participant a standard series of questions such as, “How old were you the first time that you had intercourse with another person?” Or, “How many times a week do you masturbate?”

Satisfaction in a sexual relationship is influenced by feelings of intimacy and successful communication as well as by the experience of orgasm.

322 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

regard to the experience of orgasm. Only 29 percent of women reported that they always have an orgasm with a specific partner, compared to 75 percent of men. Second, notice that 44 percent of men reported that their partners always had orgasms during sex. This figure is much higher than the rate reported by women themselves. There are several plausible explanations for this dis- crepancy. Because female orgasm is sometimes less clearly defined than male orgasm, men may misinterpret some events as signs that their partners have had an orgasm. It may also be the case that women sometimes mislead their partners into thinking that they have reached orgasm so that their partners will feel better about their own sexual prowess (Wiederman, 1997).

Figure 12.2 depicts data on participants’ ratings of physical and emotional satisfaction. Here the differences between men and women are less marked. You might expect that physical and emo- tional satisfaction in a sexual relationship would be influenced by the experience of orgasm, but the relations among these variables are complex. A relationship may be considered intimate and satis- fying simply because sexual activity occurs, regardless of whether it always results in orgasm. In fact, a large proportion of both men and women indicated that they were extremely satisfied with their partners, on both the physical and emotional dimensions. Notice in particular that, although only 29 percent of women in- dicated that they always have an orgasm with their partner, 41 percent of women said that they were extremely physically satis- fied with their partners. This pattern suggests that the experience of orgasm is only one aspect of sexual satisfaction, especially for women. Other aspects of the relationship, including tenderness, intimacy, and affection, are also critically important (Mitchell & Graham, 2008; Tiefer, 2001).

Strong negative emotions, such as anger, fear, and resent- ment, are often associated with sexual dissatisfaction. In some

in which normal couples evaluate their own sexual activities be- fore we consider specific symptoms of sexual dysfunction.

One important set of data regarding normal sexual behavior and satisfaction was collected by the National Health and So- cial Life Survey (NHSLS), the first large-scale follow-up to the Kinsey reports (Laumann, Paik, & Rosen, 1994). The NHSLS research team conducted detailed, face-to-face interviews with nearly 3,500 men and women between the ages of 18 and 59 throughout the United States. Their questionnaire asked about masturbation and four basic sexual techniques involving part- ners: vaginal intercourse, fellatio, cunnilingus, and anal in- tercourse. The results indicate that masturbation is relatively common among both men and women. Virtually all of the men (95 percent) and women (97 percent) had experienced vaginal intercourse at some time during their lives. The investigators concluded that the vast majority of heterosexual encounters fo- cus on vaginal intercourse. Most of the men (75 percent) and women (65 percent) also reported that they had engaged in oral sexual activities (as both the person giving and receiving oral- genital stimulation). Most sexual activity occurs in the context of monogamous relationships. Most of these conclusions regard- ing rates and types of sexual behaviors have been confirmed by a more recent survey conducted by investigators from the Kinsey Institute at Indiana University (Herbenick, Reece, Schick, Sanders, Dodge, Fortenberry, 2010).

One of the most interesting aspects of the NHSLS results in- volves the ways in which the participants described the quality of their experiences during sexual activity. Figure 12.1 illustrates the proportion of people who said that they always had an orgasm during sexual activity with their primary partner during the past year. Several aspects of these data are worth mentioning. First, there is a very large difference between men and women with

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figure 12.1 Sexual Response in Primary Partnership During Previous Year This graph illustrates the frequency of orgasmic response as well as differ- ences in perception by men and women in their partners’ responses. Source: Based on Laumann, Edward O., John H. Gagnon, Robert T. Michael and Stuart Michaels. 1994. The Social Organization of Sexuality: Sexual Practices in the United States. University of Chicago Press.

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figure 12.2 Sexual Satisfaction in Primary Partnership During the Previous Year This graph illustrates the physical and emotional satisfaction reported by men and women in their primary partnerships. Source: Based on Laumann, Edward O., John H. Gagnon, Robert T. Michael and Stuart Michaels. 1994. The Social Organization of Sexuality: Sexual Practices in the United States. University of Chicago Press.

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Sexual problems typically occur in the context of an intimate relationship. Problems in that relationship and the feelings of the person’s partner are obviously important, but we must be cau- tious in weighing their diagnostic importance. A panel of leading experts on women’s reproductive health recommended that the only consideration should be personal distress experienced by the woman (Basson, Berman, Burnett, Derogatis, Ferguson, Four- croy, 2000). The satisfaction and concerns of her partner is an important consideration in terms of their relationship itself, but it should not be grounds for assigning to the woman a diagnosis of sexual dysfunction unless she is personally dissatisfied with her own sexual experience.

Male HYPoactive Sexual DeSiRe DiSoRDeR Sexual desire sets the stage for sexual arousal and orgasm. Some clini- cians refer to sexual desire as the person’s willingness to approach or engage in those experiences that will lead to sexual arousal.

cases, these emotional states appear before the onset of the sexual problem, and sometimes they develop later. Given the connec- tion that many cultures make between virile sexual performance and “manhood,” it is not surprising that men with erectile dif- ficulties are often embarrassed and ashamed. Their humiliation can lead to secondary problems, such as anxiety and depression. Similar feelings frequently accompany early ejaculation and the recognition that a partner’s sexual expectations have not been fulfilled. Women who have trouble becoming aroused or reach- ing orgasm also frequently experience profound frustration and disappointment. The emotional consequences of sexual problems can be devastating for both partners.

Diagnosis DSM-5 subdivides sexual dysfunctions into several types (see Table 12.1). The diagnostic criteria for these problems are much less specific than those used to define other kinds of disorders in DSM-5. Much is left to the judgment of the individual cli- nician. Failure to reach orgasm is not considered a disorder un- less it is persistent or recurrent and results in marked distress or interpersonal difficulty. The DSM-5 criteria also require that the sexual dysfunction is not better explained by another mental disorder (such as major depression) and is not the direct result of a chemical substance (such as alcohol) or a general medical condition.

Two diagnostic criteria that are required for all forms of sexual dysfunction defined in DSM-5 are that: (1) the symptoms have persisted for at least six months, and (2) the symptoms lead to marked distress in the person who experiences them (Segraves, Balon, & Clayton, 2007). In other words, someone who is not interested in sex or who experiences problems in sexual respon- siveness would not qualify for a diagnosis of sexual dysfunction until the problems have been evident for six months and unless this circumstance is upsetting to him or her.

table 12.1 Sexual Dysfunctions Listed in DSM-5 Male Hypoactive Sexual Desire Disorder: Persistent or recurrent lack of desire for sex and deficient/absent erotic thoughts or fantasies regarding sexual activities.

erectile Disorder: Repeated failure to obtain or maintain erections during partnered sexual activities.

Female Sexual interest/arousal Disorder: Absence or reduced frequency or intensity of several indicators of interest in or response to sexual cues.

Female orgasmic Disorder: Difficulty in experiencing orgasm and/or markedly reduced intensity of orgasmic sensations.

Delayed ejaculation: Marked delay in or inability to achieve ejaculation.

Premature (early) ejaculation: Ejaculation occurs prior to or shortly after vaginal penetration.

Genito-Pelvic Pain/Penetration Disorder: Refers to a set of frequently overlapping symptoms involving having difficulty with intercourse, genito-pelvic pain, fear of pain or vaginal penetration, and tension of the pelvic floor muscles.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright © 2013 by the American Psychiatric Association.

Low sexual desire can reflect the impact of many factors ranging from unhappiness (including anger and worry) to poor physical health.

324 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

treated by Bernie Zilbergeld, an expert in the treatment of sexual dysfunction.

Erectile Disorder Norm and Linda are both 44 and have been married 15 years. Individually, they are very different. Linda is attractive, vivacious, and very critical. Norm seemed generally timid and reluctant to express his feelings. (They) had a serviceable relationship in many ways. The only problem, as far as they were concerned, was sex. When they first met, Linda was far more sexually experienced than Norm. But he tried to be a good student and they enjoyed frequent lovemaking at the beginning, although not as frequent or as passionate as she would have liked.

Over the years, however, Norm gradually lost interest in sex and developed erection problems. Either he wouldn’t get an erection or he would lose it before or during insertion. Linda ap- peared to be hurt and angry in my individual session with her. “I know you’re sympathetic toward men with erection problems. But what about me? How can I feel loved or desirable when he can’t get it up for me? It’s obvious he doesn’t want me, doesn’t desire me. I feel (awful).”

In my session with Norm, he repeated that he loved Linda and wanted to stay with her. When I asked if he found her sexu- ally attractive, he hesitated and then said yes. I asked how he felt when he was first dating her. He began by saying how beautiful he found her and how surprised he was that a woman like her would take an interest “in a nerd like me.” When I asked what else he felt at that time, he answered, “To tell the truth, I was frightened by her experience and sexual openness. It was like I was in kindergarten and she was a professor. I’m not sure I’ve ever gotten over that. I’ve always felt at least a little inadequate. And things really got bad after I started having trouble with erec- tions.” (Zilbergeld, 1995, pp. 315–316).

Norm and Linda experienced the frustrations and anxiety that often accompany sexual arousal difficulties. Their relation- ship also illustrates the marital distress that can develop when people begin to have problems with self-esteem and doubts about the affection of their partner.

FeMale Sexual inteReSt/aRouSal DiSoRDeR Low sex- ual interest and reduced sexual arousal are combined in one diag- nostic category for women. Impaired sexual arousal in women is somewhat more difficult to describe and identify than is erectile dysfunction in men. Put simply, a woman is said to experience inhibited sexual arousal if she cannot either achieve or main- tain genital responses, such as lubrication and swelling, that are necessary to complete sexual intercourse. Low sexual desire may reflect either insensitivity to cues that would be expected to stimu- late sexual interest or enhanced activity of mechanisms that inhibit sexual interest (Bloemers, van Rooij , Poels, Goldstein, Everaerd, Koppeschaar, Chivers, Gerritsen, van Ham, Olivier, Tuiten, 2013).

Hypoactive sexual desire is defined in terms of subjective ex- periences, such as lack of sexual fantasies and lack of interest in sexual experiences. The absence of interest in sex must be both persistent and pervasive to be considered a clinical problem (Carvalheira, Brotto, & Leal, 2010).

The absolute frequency with which a person engages in sex cannot be used as a measure of inhibited sexual desire because the central issue is interest—actively seeking out sexual experi- ences—rather than participation (Warnock, 2002). For example, some people acquiesce to their partners’ demands, even though they would not choose to engage in sexual activities if it were left up to them. In the absence of any specific standard, the identi- fication of hypoactive sexual desire must depend on a clinician’s subjective evaluation of the level of desire that is expected given the person’s age, gender, marital status, and many other relevant considerations.

Almost everyone recognizes that sexual desire fluctuates in intensity over time, sometimes dramatically and frequently, for reasons that we do not understand. The fact that hypoactive sexual desire is listed in DSM-5 as a type of disorder should not lead us to believe that it is a unitary condition with a simple explanation. It is, in fact, a collection of many different kinds of problems. People who suffer from low levels of sexual de- sire frequently experience other mental and medical disorders. Most men seeking treatment for hypoactive sexual desire re- port other forms of sexual dysfunction, such as problems with arousal or genital pain. Men and women with low sexual desire also have high rates of mood disorders. The mood disorder typ- ically appears before the onset of low sexual desire. It appears likely, therefore, that many cases of low sexual desire develop after the person has experienced other forms of psychological distress.

eRectile DiSoRDeR Many men experience difficulties either in obtaining an erection that is sufficient to accomplish inter- course or maintaining an erection long enough to satisfy them- selves and their partners during intercourse. Both problems are examples of erectile dysfunction. Men with this problem may report feeling subjectively aroused, but the vascular reflex mechanism fails, and sufficient blood is not pumped to the penis to make it erect (Wylie & Machin, 2007). These difficul- ties can appear at any time prior to orgasm. Some men have trouble achieving an erection during sexual foreplay, whereas others lose their erection around the time of insertion or dur- ing intercourse. This phenomenon used to be called impo- tence, but the term has been dropped because of its negative implications.

Erectile dysfunctions can be relatively transient, or they can be more chronic. Occasional experiences of this type are not considered unusual. When they persist and become a serious source of distress to the couple, however, erectile difficulties can lead to serious problems. Consider, for example, the feelings ex- pressed by the man and woman in our next case study, who were

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 325

FeMale oRGaSMic DiSoRDeR Some women are unable to reach orgasm even though they apparently experience uninhib- ited sexual arousal. Women who experience orgasmic difficulties may have a strong desire to engage in sexual relations; they may find great pleasure in sexual foreplay and may show all the signs of sexual arousal. Nevertheless, they cannot reach the peak erotic experience of orgasm. Women whose orgasmic impairment is generalized have never experienced orgasm by any means. Situa- tional orgasmic difficulties occur when the woman is able to reach orgasm in some situations, but not in others. That might mean that she is orgasmic during masturbation but not during inter- course, or perhaps she is orgasmic with one partner but not with another (Basson, 2002).

Orgasmic disorder in women is somewhat difficult to de- fine in relation to inhibited sexual arousal because the various

The capacity for intercourse is less obvious and more dif- ficult to measure for a woman than for a man, whose erect pe- nis usually serves as a signal of readiness (see Research Methods box). Investigators who have studied sexual responses in nor- mal women have reported low correlations between self-reports of subjective arousal and physiological measures, such as the amount of vaginal lubrication or vasocongestion (Meston, Rellini & McCall, 2010). Among women who experience sex- ual difficulties, the problem may more often be decreased sub- jective arousal rather than impaired physiological responses. The distinction between desire and subjective arousal is diffi- cult to make. That is why hypoactive sexual desire and sexual arousal disorder were combined into one diagnostic category for women in DSM-5 (Basson & Brotto, 2009; Giraldi, Rellini, Pfaus, Laan, 2013).

ReseaRch methods

Hypothetical Constructs: What Is Sexual Arousal?

The term sexual arousal refers to the state that precedes orgasm. It is defined in terms of two factors: physiological responses, such as vascular engorgement of the genitals, and subjective feelings of pleasure and excitement. Psycholo- gists refer to sexual arousal as a hypothetical construct. Many of the concepts that we have discussed in this book are hypo- thetical constructs: anxiety, depression, psychopathy, and schizo- phrenia. Hypothetical constructs are theoretical devices. In the field of psychopathology, they refer to events or states that re- side within the person and are proposed to help us understand or explain a person’s behavior.

Constructs cannot be observed directly, but in order to be scientifically meaningful they must be defined in terms of observable responses (Cronbach & Meehl, 1955; Kimble, 1989). These responses are all associated with the construct, but they are not perfectly related, and the construct is not exhaustively defined by them. For example, an erect penis is not always accompanied by subjective feelings of sexual excitement, and subjective feelings of arousal are not always associated with physiological responses. In other words, the construct of sexual arousal is anchored by feelings and responses that can be measured directly, but it is more than the sum of these parts.

An operational definition is a procedure that is used to mea- sure a theoretical construct. Such a definition usually includes measures of the different components of the construct. For men, one obvious component of sexual arousal is penile erec- tion. The most widely accepted procedure for measuring male sexual arousal uses a device called a penile plethysmograph (Rosen, Weigel, & Gendrano, 2007). In this procedure, the man places a thin elastic strain gauge around his penis, underneath

his clothing. The rubber loop is filled with a column of mercury that changes in its electrical conductance as the circumference of the penis changes. The wire extending from the strain gauge is connected to a plethysmograph, which amplifies the electrical signal passing through the strain gauge and produces a record reflecting changes in penile tumescence.

The vaginal photometer, a device shaped like a tampon and in- serted into the vagina, is used to measure female sexual arousal. Like the penile strain gauge, the photometer can be placed in position in private and worn underneath clothing during the as- sessment procedure. As the woman becomes sexually aroused, the walls of the vagina become congested with blood. Vaso- congestion causes changes in the amount of red light that can be transmitted through the tissue. The photometer is sensitive to subtle changes in vaginal tissue and is probably most useful in measuring moderate to low levels of sexual arousal (Janssen, 2002; Prouse & Heiman, 2009).

Clinical scientists must always think carefully about the meaning of their operational definitions. Although the penile strain gauge and the vaginal photometer measure physiological events that are directly related to sexual arousal, the responses that they measure are not the same thing as sexual arousal. They are reflections of the construct, which has many dimensions (Berman, Berman, Werbin, Flaherty, Leahy, Goldstein, 1999). One impor- tant goal of scientific studies is to determine more specifically how (and when) these physiological measures are related to the other observable referents of sexual arousal. This process will determine the construct validity of the penile strain gauge and the vaginal photometer—that is, the extent to which these specific measures produce results that are consistent with the theoretical construct.

326 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

In order to assign the diagnosis, the clinician must determine that the person shows a normal interest in and response to sexual stimuli and has then engaged in activity that would otherwise be considered sufficient to lead to an orgasmic response for other men.

Genito-Pelvic Pain/PenetRation DiSoRDeR This diag- nostic category is used to describe four types of problems that often occur together: genito-pelvic pain, fear of pain or vaginal penetration, tension of the pelvic floor muscles, and trouble hav- ing intercourse. Some people experience persistent genital pain during or after sexual intercourse, which is known as dyspareunia. The problem can occur in either men or women, although it is considered to be much more common in women (Davis & Reissing, 2007). The severity of the discomfort can range from mild irritation following sexual activity to searing pain during insertion of the penis or intercourse. The pains may be sharp and intense, or they may take the form of a dull, aching sensation; they may be experienced as coming from a superficial area near the barrel of the vagina or as being located deep in the lower ab- dominal area; they may be intermittent or persistent. The experi- ence of severe genital pain is often associated with other forms of sexual dysfunction. Not surprisingly, many women with dyspa- reunia develop a lack of interest in, or an aversion toward, sexual activity.

The following first-person account was written by a 40-year- old woman who had been experiencing vaginal pain for several months. She had consulted several different health professionals about the problem, and none of their treatments had relieved her discomfort. This passage describes her experience one night when she and the man with whom she had been living seemed to be on the brink of enjoying a renewed interest in their sexual relationship.

Genital Pain We went to bed. For a while it was nice—more than nice. It was novel and thrilling, as if we had just met. We hadn’t approached each other in more than a month. I was surprised by how wonder- ful I could feel. I was used to feeling lousy most of the time. The sensations of excitement were overwhelming. I’d forgotten about that. Then he pushed himself into me and it was horrible.

First I felt as if I were being torn or sliced. As he settled into a rhythm, I felt that something was scraping me over and over in the same raw spot, until the rawness and soreness were all I could feel. He didn’t notice. He was intent on what he was doing. I decided to let him get on with it, but the pain was really bothering me. I pulled away inside myself, so that the events on the bed were far from where “I” was, and the pain was far away also. That worked, but I didn’t like doing it. There was something nasty about it. I had the thought, People who don’t like sex must feel this way. Then I realized that now I was somebody who didn’t like sex (Kaysen, 2001, pp. 60–61).

components of female sexual response are more difficult to mea- sure than are erection and ejaculation in the male. One experi- enced researcher described this issue in the following way:

In my experience, many women who have never reached orgasm present the following set of symptoms: They report that when engaging in intercourse they do not have difficulty lubricating and experience no pain. However, they report no genital sensations (hence the term genital anesthesia) and do not appear to know what sexual arousal is. Typically they do not masturbate and often have never masturbated. They do not experience the phenomenon that a sexually functional woman would call sexual desire. Most of these women seek therapy because they have heard from others or have read that they are missing something, rather than because they them- selves feel frustrated. (Morokoff, 1989, p. 74)

PReMatuRe (eaRlY) ejaculation Many men experience problems with the control of ejaculation. They are unable to pro- long the period of sexual excitement long enough to complete intercourse. This problem is known as premature ejaculation, but most experts now prefer the term early ejaculation because it is less pejorative. Once they become intensely sexually aroused, they reach orgasm very quickly (Metz & Pryor, 2000). Almost all the literature on this topic is concerned with men, but some women are also bothered by reaching orgasm too quickly. There- fore, some clinicians have suggested that “early orgasm” might be a more appropriate description of the problem.

There have been many attempts to establish specific, quanti- tative criteria for premature ejaculation (Broderick, 2006). None of the attempts has been entirely satisfactory, but certain bound- aries identify conditions that can be problematic. If the man ejac- ulates before or immediately upon insertion, or after only three or four thrusts, almost all clinicians will identify his response as pre- mature ejaculation. Among men suffering from lifelong prema- ture ejaculation, 90 percent routinely ejaculate within one minute after insertion of the penis in the vagina (Waldinger, 2009).

Another way to think about premature ejaculation places emphasis on subjective control and the couple’s satisfaction rather than on the amount of time required to reach orgasm. The DSM-5 definition defines the problem in terms of recurrent ejaculation shortly after penetration and before the person wishes it. If pro- gression to orgasm is beyond the man’s voluntary control once he reaches an intense level of sexual arousal, he has a problem with premature ejaculation (Symonds, Roblin, Hart, Althof , 2003).

DelaYeD ejaculation The central feature of this disorder, which has also been called male orgasmic disorder and ejaculatory inhibition, involves a marked delay in ejaculation, or an inability to accomplish ejaculation (Foley, 2009). The problem is defined in terms of sexual behavior with a partner. It must be experienced in most sexual encounters (at least 75% of the time), and it must not be the result of voluntary efforts by the man to delay orgasm.

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 327

Access to the vagina is controlled by the muscles surrounding its entrance. Some women find that whenever penetration of the vagina is attempted, these muscles snap tightly shut, preventing insertion of any object. This involuntary muscular spasm, known as vaginismus, prevents sexual intercourse as well as other activi- ties, such as vaginal examinations and the insertion of tampons. Women with vaginismus may be completely sexually responsive in other respects, fully capable of arousal and orgasm through manual stimulation of the clitoris. Women who seek therapy for this condition often report that they are afraid of intercourse and vaginal penetration (Reissing, Binik, Khalife, Cohen, Amsel, 2004). The problem can be severe or partial in nature. Some cou- ples report that a mild form of vaginismus occurs from time to time, making intercourse difficult and sometimes painful.

The definition of genito-pelvic pain/penetration disorder in DSM-5 is more broadly conceived than the approach to these problems that was represented in previous versions of the diag- nostic manual. Many women experience genital pain during sex- ual stimulation other than intercourse. Traditional definitions of dyspareunia and vaginismus focus exclusively on problems that occur during sexual intercourse. Some experts have suggested that these problems should be viewed as genital pain disorders (simi- lar to pain disorders, such as back pain) that interfere with inter- course rather than as forms of sexual dysfunction (Binik, 2005).

Frequency Surveys conducted among the general population indicate that some forms of sexual dysfunction are relatively common (Chris- tensen, Grønbæk, Osler, Pedersen, Graugaard, Frisch, 2011). We must keep in mind, however, that this impression is based on self- report questionnaires and judgments made by laypersons, which are less precise than those made by experts. Diagnoses made by experienced therapists would take into account the person’s age, the context of the person’s life, and whether the person had ex- perienced stimulation that would ordinarily be expected to lead to sustained arousal and orgasm. Clinicians would also consider the amount of distress and interpersonal difficulty associated with the problem before arriving at a diagnosis of sexual dysfunction. Therefore, we must be cautious in our interpretations of survey data (Hayes, Dennerstein, Bennett, Fairleyl, 2008).

The most extensive set of information regarding sexual prob- lems among people living in the community comes from the National Health and Social Life Survey (NHSLS). Each partici- pant was asked whether during the past 12 months he or she had experienced “a period of several months or more when you lacked interest in having sex; had trouble achieving or maintaining an erection or (for women) had trouble lubricating; were unable to come to a climax; came to a climax too quickly; or experienced physical pain during intercourse.” For each item, the person was asked for a simple yes or no response. Figure 12.3 indicates the overall percentage of men and women who indicated that they had experienced each of these specific problems. There are

figure 12.3 Prevalence of Sexual Dysfunctions This graph shows the percent- age of NHSLS respondents who reported having sexual difficulties at some time during the previous 12 months. Note the differences in the problems reported by men and women. Source: Based on Laumann, Edward O., John H. Gagnon, Robert T. Michael and Stuart Michaels. 1994. The Social Organization of Sexuality: Sexual Practices in the United States. University of Chicago Press.

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obviously significant gender differences in the prevalence of all types of problems. Premature ejaculation is the most frequent form of male sexual dysfunction, affecting almost one out of ev- ery three adult men. All the other forms of sexual dysfunction are reported more often by women. One-third of women said that they lacked interest in sex, and almost one-quarter indicated that they experienced a period of several months during which they were unable to reach orgasm (Laumann, Paik, & Rosen, 1999).

Sexual BeHavioR acRoSS tHe liFe SPan Sexual behavior changes with age. Masters and Johnson devoted considerable attention to this topic in their original studies. Their data chal- lenged the myth that older adults are not interested in, or capable of performing, sexual behaviors. The NHSLS data also indicate that many people remain sexually active later in life. Gender differences become marked in the late fifties, when rates of in- activity increase dramatically for women. Between ages 70 and 74, 65 percent of men are still sexually active, compared to only 30 percent of women. These differences may be, at least partly, the result of differential mortality rates (men die earlier, so many women lose their partners) as well as biological factors that are part of the aging process. They may also reflect the influence of a cultural prejudice against sexual activity among older women.

Differences between younger and older people are mostly a matter of degree. As men get older, they tend to achieve erec- tions more slowly, but they can often maintain erections for lon- ger periods of time. Older men find it more difficult to regain an erection if it is lost before orgasm. As women get older, vaginal lubrication may occur at a slower rate, but the response of the cli- toris remains essentially unchanged. The intensity of the subjec- tive experience of orgasm is decreased for older men and women. For both men and women, healthy sexual responsiveness is most likely to be maintained among those who have been sexually active as younger adults (Herbenick et al., 2010).

328 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

sexual experiences and satisfaction of people living in non-Western cultures (Ghanem & El-Sakka, 2007).

causes At each stage of the sexual response cycle, a person’s behavior is determined by the interaction of many biological and psychologi- cal factors, ranging from vasocongestion in the genitals to com- plex cognitive events involving the perception of sexual stimuli and the interpretation of sexual meanings. Interference with this system at any point can result in serious problems. In the follow- ing pages, we review some of the factors that contribute to the etiology of various types of sexual dysfunctions.

BioloGical FactoRS The experience of sexual desire is partly controlled by biological factors. Sexual desire is influenced by sex hormones for both men and women (LeVay & Valente, 2003). Testosterone is particularly important for male sexual desire. Stud- ies of men with inadequate levels of sex hormones show an in- hibited response to sexual fantasies, but they are still able to have erections in response to viewing explicit erotic films. The influence of male sex hormones on sexual behavior is, therefore, thought to be on sexual appetite rather than on sexual performance. This process probably involves a threshold level of circulating testoster- one (Schiavi & Segraves, 1995). In other words, sexual appetite is impaired if the level of testosterone falls below a particular point (close to the bottom of the laboratory normal range), but above that threshold, fluctuations in testosterone levels will not be as- sociated with changes in sexual desire. The reduction of male sex hormones over the life span probably explains, at least in part, the apparent decline in sexual desire among elderly males.

The prevalence of certain types of sexual dysfunctions in- creases among the elderly, particularly among men (DeRogatis & Burnett, 2008). In the NHSLS, for example, the proportion of men reporting erectile problems increased from 6 percent in the 18–24 age range to 20 percent in the 55–59 age range. In contrast, several types of sexual problems actually declined in frequency among older women. Women in the 55–59 age range were less likely than women between the ages of 18 and 24 to report pain during sex or inability to reach orgasm, although they did report a slight increase in trouble with lubrication during sex- ual activity.

The relation between sexual experience and aging is closely related to other health problems that increase with age. People who rate their health as being excellent have many fewer sexual problems than people who rate their health as being only fair or poor (Laumann, Das, & Waite, 2008).

cRoSS-cultuRal coMPaRiSonS Patients with sexual disor- ders seek treatment at clinics all over the world (Steggall, Gann, & Chinegwundoh, 2004). Therefore, these problems are not unique to any particular culture. Cultural and ethnic differences have been reported for sexual practices, beliefs about sexuality, and patterns of sexual decision making. For example, Asians are more conserva- tive than Caucasians in many regards, such as the prevalence and frequency of masturbation (Meston, Trapnell, & Gorzalka, 1996). It is not clear whether variations in sexual behavior are accompa- nied by cultural differences in the frequency and form of sexual dysfunctions. Cross-cultural studies of prevalence rates for specific sexual dysfunctions have not been reported. This kind of investi- gation may be difficult to perform because the DSM-5 definitions of sexual dysfunctions may not be well suited to describing the

Many people remain sexually active later in life. Differences in sexual responsive- ness between younger and older people are mostly a matter of degree.

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 329

(Nobre & Pinto-Gouveia, 2006). Women seeking treatment for low interest in sex report negative perceptions of their parents’ at- titudes regarding sexual behavior and the demonstration of affec- tion. In comparison to other women, they also indicate that they feel less close to their husbands, have fewer romantic feelings, and are less attracted to their husbands. The quality of the relation- ship is an important factor to consider with regard to low sexual desire (Metz & Epstein, 2002).

Culturally determined attitudes toward sexual feelings and behaviors can also have a dramatic impact on women’s ability to become sexually aroused (Al-Sawaf & Al-Issa, 2000). Some soci- eties openly encourage female sexuality; others foster a more re- pressive atmosphere. Within U.S. culture, there are tremendous variations with regard to women’s ability to experience and ex- press their sexuality. For example, many women feel guilty about having sexual fantasies, in spite of the fact that such fantasies are extremely common. Women who feel guilty about fantasizing while they are having intercourse are more likely to be sexually dissatisfied and to encounter sexual problems. The most im- portant factors contributing to failure to reach orgasm involve negative attitudes, feelings of guilt, and failure to communicate effectively (Kelly, Strassberg, & Turner, 2004).

Couples that experience communication problems, power conflicts, and an absence of intimacy and trust are more likely than others to experience sexual problems. Lack of assertiveness and lack of comfort in talking about sexual activities and plea- sures are associated with various types of female sexual dysfunc- tions (Rosen & Leiblum, 1995). The following brief case study provides one example of serious relationship difficulties that were experienced by one couple in which the woman, a married, 34-year-old lawyer, was being treated for long-standing vaginis- mus as well as alcohol dependence.

Penetration Difficulty and Alcohol Dependence Gina speculated that living with Paul exacerbated her sexual anxieties, and she became increasingly dependent on alcohol to “loosen her up” sexually. Paul was sexually naive and did not press Gina to have intercourse, especially when she so visibly pan- icked at the approach of his penis. He, too, was sexually anxious and was afraid of inflicting pain on her. Sexually, they depended on drinking to disinhibit them, and they developed a sexual script that relied on manual stimulation and oral sex. Although sexual contact was relatively infrequent, both were reasonably content.

This state of affairs continued for many years. It was not without its costs, though. Gina felt inadequate and deficient as a woman and avoided gynecological examinations. Paul would oc- casionally become enraged at a seemingly small provocation and verbally attack Gina. Internally, he reported feeling humiliated, emasculated, and ashamed about the non-consummation of their marriage. When his coworkers teased and joked about “getting it on” sexually, he felt alone in the private knowledge that he had never penetrated his wife despite 13 years of living and sleeping together.

Many cases of erectile dysfunction can be attributed to vas- cular, neurological, or hormonal impairment (Goldstein, 2004). Erection is the direct result of a threefold increase in blood flow to the penis. Thus, it is not surprising that vascular diseases, which may affect the amount of blood reaching the penis, are likely to result in erectile difficulties. Neurological diseases, such as epilepsy and multiple sclerosis, can also produce erectile dif- ficulties, because erection depends on spinal reflexes. Diabetes may be the most common neurologically based cause of impaired erectile responsiveness.

Various kinds of drugs can also influence a man’s erectile response (Clayton & West, 2003). One interesting set of results indicates that men who smoke cigarettes are more likely to expe- rience erectile difficulties than are men in the general population. Many other drugs, including alcohol and marijuana, may have negative effects on sexual arousal.

A number of biological factors can impair a woman’s abil- ity to become sexually aroused (Clayton, 2007). Various types of neurological disorders, pelvic disease, and hormonal dysfunction can interfere with the process of vaginal swelling and lubrication. Although relatively little research has been conducted on sexual arousal in women, there is evidence to suggest that genetic factors influence the frequency with which women are able to experience orgasm (Dawood, Kirk, Bailey, Andrews, Martin, 2005).

Inhibited orgasm, in both men and women, is sometimes caused by the abuse of alcohol and other drugs. The problem may improve if the person is able to stop drinking and maintain a stable period of sobriety (Schiavi & Segraves, 1995). Orgasm problems can also be associated with the use of prescribed forms of medication. For example, as we discussed in Chapter 5, many people who take SSRIs such as fluoxetine (Prozac) for the treat- ment of depression have difficulty achieving orgasm as a side effect (Werneke, Northey, & Bhugra, 2006).

PSYcHoloGical FactoRS Although sexual desire is rooted in a strong biological foundation, psychological variables also play an important role in the determination of which stimuli a person will find arousing. Sexual desire and arousal are determined, in part, by mental scripts that we learn throughout childhood and adoles- cence (Middleton, Kuffel, & Heiman, 2008; Wiegel, Scepkowski, & Barlow, 2007). These scripts provide structure or context to the otherwise confusing array of potential partners who might become the object of our desires. In other words, there are certain kinds of people to whom we may be sexually attracted, and there are certain circumstances in which sexual behavior is considered ap- propriate. According to this perspective, the personal meaning of an event is of paramount importance in releasing the biological process of sexual arousal. Both members of the potential couple must recognize similar cues, defining the situation as potentially sexual in nature, before anything is likely to happen.

Beliefs and attitudes toward sexuality, as well as the quality of interpersonal relationships, have an important influence on the development of low sexual desire, especially among women

330 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

clinic in St. Louis went through a two-week course of assessment and therapy in which they became more familiar with their bod- ies, learned to communicate more effectively with their partners, and received training in procedures designed to help them di- minish their fears about sexuality. The results of this treatment program were very positive and quickly spawned a burgeoning industry of psychosocial treatment for sexual dysfunction. Get- ting Help at the end of this chapter discusses some of the options and resources available to anyone experiencing problems in sexual functioning or health.

PSYcHoloGical PRoceDuReS Psychological treatments for sexual dysfunction address several of the causes discussed earlier, especially negative attitudes toward sexuality, failure to engage in effective sexual behaviors, and deficits in communication skills. Sex therapy centers around three primary types of activities: sen- sate focus and scheduling; education and cognitive restructuring; and communication training (Meston & Rellini, 2008; Wincze, Bach, & Barlow, 2008).

The cornerstone of sex therapy is known as sensate focus, a series of simple exercises in which the couple spends time in a quiet, relaxed setting, learning to touch each other. They may start with tasks as simple as holding hands or giving each other back rubs. The rationale for sensate focus hinges on the recog- nition that people with sexual problems must learn to focus on erotic sensations rather than on performance demands. The goal is to help them become more comfortable with this kind of phys- ical sharing and intimacy, to learn to relax and enjoy it, and to talk to each other about what feels good and what does not.

Another facet of psychological approaches to treating sexual dysfunction involves scheduling. This is, in fact, closely related to sensate focus because the technique of sensate focus requires that people schedule time for sex. Couples need a quiet, relaxed, and private environment in order to engage in pleasurable and satisfy- ing sexual behavior.

Eventually, as Gina’s drinking escalated, the marital conflict grew intolerable. When Gina was drunk, she would verbally be- rate and abuse Paul. Her attacks and complaints about his passiv- ity and lack of assistance with housework and her disparagement of his passion for sports undermined the earlier closeness they had experienced. Although he would usually tolerate her drunken tirades silently, he began to blow up more readily (Leiblum, 1995, p. 256).

Previous harmful or traumatic experiences can also have an important effect on various aspects of sexual interests and arousal. A previous history of sexual abuse can cause aversion to sexual stimuli, and it can interfere with a woman’s ability to become sex- ually aroused (Najman, Dunne, Purdie, Boyle, Coxeter, 2005). Premature ejaculation and low sexual desire in men have also been linked to various kinds of long-lasting, adverse relationships with adults during childhood (Loeb, Williams, Carmona, Rivkin, Wyatt, Chin, 2002). For example, boys who grow up in a home in which their father is physically abusive may learn to associate sex with violence and become convinced that they do not want to function—sexually or interpersonally—as their father had.

Performance anxiety and fear of failure are among the most important psychological factors contributing to impaired sexual arousal. People who have experienced inhibited sexual arousal on one or two occasions may be likely to have further problems to the degree that these difficulties make them more self-conscious or apprehensive regarding their ability to become aroused in fu- ture sexual encounters. Several prominent and experienced sex therapists have assumed that anxiety and sexual arousal are in- compatible emotional states. People who are anxious will pre- sumably be less responsive to sexual stimuli. And men who have sexual arousal disorders are more likely to report feeling high lev- els of performance anxiety (McCabe, 2005).

Anxiety disrupts sexual performance to the extent that it al- ters certain cognitive processes. Several studies have compared the responses of sexually dysfunctional men with those of con- trol subjects in laboratory settings. Dysfunctional men experience more negative emotions in the presence of erotic stimuli, and they are also more likely to shift their attention from the arous- ing properties of sexual stimuli to the threatening consequences of potential failures in sexual performance (Bach, Brown, & Barlow, 1999). In comparison to men without erectile disorder, men with sexual dysfunction rate negative sexual events as being more important and then are more likely to attribute the problem to something about themselves rather than external considerations (Scepkowski, Wiegel, Bach, Weisberg, Brown, Barlow, 2004).

treatment Masters and Johnson (1970) were pioneers in developing and popularizing a short-term, skills-based approach to the treatment of sexual dysfunctions. Hundreds of couples who visited their

Sensate focus exercises help people become aware of physical sensa- tions that are associated with touching and being touched while minimizing demands for sexual performance.

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 331

culture. Some societies value and encourage sharp differences in gender roles, with men being expected to make decisions about the timing and type of sexual activity (Quadagno, Sly, Harrison, Eberstein, Soler, 1998). Therefore, communication training must be tailored to meet the expectations that each couple holds re- garding the nature of their relationship. Mental health profes- sionals must give careful consideration to their clients’ cultural background when they conduct an assessment and design a treat- ment program.

BioloGical tReatMentS Biological treatments— primarily medications—are also useful in the treatment of sexual dysfunc- tions. This is especially true for erectile disorder, the most frequent sexual problem for which men seek professional help. Sildenafil citrate (Viagra) was approved by the FDA in 1998 for the treat- ment of erectile dysfunction and quickly became one of the most popular drugs on the market. Competing pharmaceutical com- panies soon developed and began vigorously promoting similar drugs known as tadalafil (Cialis) and vardenafil (Levitra). All three drugs are phosphodiesterase-5 (PDE-5)1 inhibitors that facilitate erection by increasing blood flow to certain areas of the penis. They increase the man’s ability to respond to stimuli that he would ordinarily find sexually arousing, but they do not influence overall sexual desire (Edwards, Hackett, Collins, Curram, 2006).

Double-blind, placebo-controlled studies have evaluated the use of Viagra in men with erectile problems associated with vari- ous conditions, including hypertension, diabetes, and coronary artery disease. It is effective, increasing the number of erections for approximately two-thirds of men with severe erectile dysfunction (Fink, MacDonald, Rutks, Nelson, Wilt, 2002). Unfortunately, some men experience negative side effects, such as headache, facial flushing, nasal congestion, and altered vision. Perhaps most important, Viagra can lead to sudden drops in blood pressure if taken with various forms of medication known as “nitrates,” which are used in the treatment of heart disease. Some deaths were reported after Viagra was introduced because of this misuse. The research evidence indicates that Viagra and other PDE-5 in- hibitors should be used in combination with psychological treat- ments for sexual dysfunction (see Critical Thinking Matters).

1PDE-5 is an enzyme that metabolizes nitric oxide, which triggers sexual arousal.

A third aspect of sex therapy involves education and cog- nitive restructuring—changing the way in which people think about sex. In many cases, the therapist needs to help the couple correct mistaken beliefs and attitudes about sexual behavior. Examples are the belief that intercourse is the only true form of sex, that foreplay is an adolescent interest that most adults can ignore, and that simultaneous orgasm is the ultimate goal of in- tercourse. Providing information about sexual behaviors in the general population can often help alleviate people’s guilt and anx- iety surrounding their own experiences. Some people are relieved to know that they are not the only ones who fantasize about vari- ous kinds of sexual experiences, or that the fact that they fantasize about these things does not mean that they are going to be com- pelled to behave in deviant ways.

The final element of psychological treatment for sexual dys- function is communication training. Many different studies have indicated that people with sexual dysfunction often have deficits in communication skills. They find it difficult to talk to their part- ners about matters involving sex, and they are especially impaired in the ability to tell their partners what kinds of things they find sexually arousing and what kinds of things turn them off. There- fore, sex therapists often employ structured training procedures aimed at improving the ways in which couples talk to each other.

The outcome results of psychological treatment programs for sexual disorders have generally been considered to be positive (Dutere, Segraves, & Althof, 2007). Early reports from Masters and Johnson’s clinic were especially glowing. One summary of their results reported an overall success rate of 85 percent for male patients and 78 percent for female patients. Unfortunately, more recent studies have reported less positive results. Serious ques- tions have been raised about the adequacy of the research meth- ods employed in several outcome studies. Interventions have not been standardized, sample sizes have been relatively small, and long-term follow-up data are often lacking. Therefore, although psychological treatments for sexual dysfunction are frequently successful, empirical support for the efficacy of these procedures is not strong (Heiman, 2002; O’Donohue, Swingen, Dopke, Regev, 1999). Better studies are clearly needed.

Important questions have also been raised about the utility of these procedures for clients in other cultures. Clinics in India, Iran, Japan, Saudi Arabia, and South Africa report that men and women from many different backgrounds seek help for sexual dysfunctions (Verma, Khaitan, & Singh, 1998). Culture dic- tates the ways in which sexual issues may be discussed, and be- liefs about sexuality and reproduction influence decisions about acceptable sexual behaviors. These beliefs vary extensively across cultures. For example, people in some Asian cultures believe that a man’s health can be damaged through unnecessary loss of se- men (Davis & Herdt, 1997). Such concerns may prohibit use of masturbation as a therapeutic exercise. Implicit rules governing communication patterns between partners are also determined by

© Alex Gregory/The New Yorker Collection/

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332 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

partners, but it is also more expensive and can lead to more fre- quent postsurgical complications, such as infection.

The various forms of treatment that are available for the treatment of sexual dysfunction are certainly promising. They of- fer several constructive options for people who are experiencing distress as a consequence of problems in sexual desire or perfor- mance. That is the good news with regard to sexual disorders. The bad news is concerned with another set of problems, which are known collectively as paraphilic disorders. They are less well understood, in comparison to the sexual dysfunctions, and they are also more difficult to treat. The next section of this chapter reviews the current state of our knowledge regarding these dif- ficult problems.

Paraphilic Disorders For some people, sexual arousal is strongly associated with un- usual activities and targets, such as inanimate objects, sexual contact with children, exhibiting their genitals to strangers, or inflicting pain on another person. These conditions are known as paraphilias. Literally translated, paraphilia means “love” (philia) “beyond the usual” (para). This term refers to conditions that were formerly called perversions or sexual deviations. The central features of all paraphilias are persistent sexual urges and fantasies

Pharmaceutical companies are also developing and evaluat- ing medications that might be used to treat sexual dysfunction in women (Korda, Goldstein, & Goldstein, 2010; van der Made, Bloemers, Yassem, Kleiverda, Everaerd, van Ham, . . . Tuiten, 2009). One product, known as Intrinsa, is a patch that delivers testosterone through the skin and could serve to increase sexual desire, especially in post-menopausal women and those who have had their ovaries removed. The FDA decided in 2004 to delay approval for Intrinsa because it did not have enough information about its long-term safety, particularly regarding increased risk for cancer and cardiovascular disease. The use of testosterone could also lead to other side effects, such as facial hair growth, deepen- ing of the voice, and the development of other masculine features in women.

Another less frequently used procedure for the treatment of erectile dysfunction involves surgically inserting a penile im- plant (or prosthesis), which can be used to make the penis rigid during intercourse (Melman & Tiefer, 1992; Schwartz, Covino, Morgenstaler, DeWolf, 2000). Several devices have been used. One option is a semi-rigid silicone rod that the man can bend into position for intercourse. Another device is hydraulic and can be inflated for the purpose of sexual activity. The man squeezes a small pump, which forces fluid into the inflatable cylinder and produces an erection. The inflatable device is preferred by

cRiTical Thinking matters

Does Medication Cure Sexual Dysfunction?

Can you remember watching a sporting event on television without seeing an advertisement for Cialis or Levitra? Attractive men and women cuddle and smile as they talk enthusiastically about the satisfaction that can be achieved with pharmacologically induced strong, lasting erections. It’s difficult to imagine a new form of treatment for a psychological disorder that has been promoted more aggressively, or achieved a more dramatic impact on public awareness, than the PDE-5 inhibi- tors. In a few short years, they have generated a market that is estimated to approach $2 billion per year. They’ve become very popular, but do these pills offer a quick fix for all people suffer- ing from arousal disorders?

Viagra and similar medications are clearly an important option for men with erectile problems. Countless men and their partners are grateful for their beneficial effects. Unfortunately, in many other cases, they are not a complete solution to sexual dysfunction in the absence of additional treatment. Couples that have experienced sexual problems have often struggled with a number of difficult is- sues for several years. Increasing the man’s capacity for erection will address only one part of the problem. As one expert puts it, “Viagra can increase blood flow to the penis, but it doesn’t create intimacy, love, or desire” (Morgentaler, 2003). Most experts recommend

a treatment approach that combines the use of medication with cognitive behavior therapy. Therapists need to work with couples to improve intimacy and communication while also helping them to overcome frustrations and anxiety that have accumulated over years (McCarthy, 2004; Rosen, 2000).

A related product for women, which the media have nicknamed the female Viagra, may be available soon. Intrinsa, a patch that delivers testosterone through the skin, is being developed to address low desire, the most frequent sexual problem reported by women (see Figure 12.3). Small doses of testosterone can increase sexual desire in some women who have had their ovaries removed, but it seems unlikely that they will be effective with women who have lost inter- est in sex because of relationship difficulties or other motivational and cognitive factors. Problems with fatigue, scheduling difficulties, anxiety, and low self-esteem are all issues that don’t go away simply because testosterone levels increase. Medication may facilitate some of the biological functions that are necessary prerequisites for healthy sexual behaviors, but it cannot guarantee that people will find their partners appealing or that sex will be pleasurable. Consumers and medical professionals all need to think critically about the complex factors that contribute to sexual dysfunction. We should not expect to find a magic bullet that will cure them all at once.

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 333

Paraphilic Disorder For the past 40 years, Jon has masturbated to images of barely clad women violently wrestling each other. Periodically through- out his marriage, he has tried to involve his wife in wrestling matches with her friends and, eventually, with their adolescent daughter. When Jon was drunk, he occasionally embarrassed his wife by trying to pick fights between her and other women. On summer vacations, he sometimes jokingly suggested the women wrestle. During much of his sober life, however, his daydreams of women wrestling were private experiences that preoccupied only him. He amassed a collection of magazines and videotapes de- picting women wrestling, to which he would resort when driven by the need for excitement.

Jon presented for help with his inability to maintain his erec- tion with his wife for intercourse. With the exception of procre- ational sex, he was not able to consummate his long marriage. He was able to (become) erect if his wife described herself wrestling other women while he stimulated his penis in front of her, but he always lost his erection when intercourse was attempted (Levine, Risen, & Althof, 1990).

This case illustrates the way in which paraphilic disorders can interfere with a person’s life, especially relationships with other people. Jon’s preoccupation with fantasies of women wrestling led him to say and do things that disrupted his marriage and his friendships with other people. Many people with paraphilic dis- orders experience sexual dysfunction involving desire, arousal, or orgasm during conventional sexual behavior with a partner. The wives of men with paraphilic disorders frequently protest that their husbands are not interested in their sexual relationship. In fact, the husband may be actively engaged in frequent masturba- tion to paraphilic fantasies. Cases of this sort present an interest- ing diagnostic challenge to the clinician, who must distinguish a paraphilia from what might otherwise appear to be low sexual desire.

Diagnosis DSM-5 requires that the erotic preoccupation must have lasted at least six months before the person would meet diagnostic cri- teria for a paraphilic disorder. Furthermore, the diagnosis of para- philic disorder is made only if the person’s paraphilic urges lead to clinically significant distress or impairment. The person would be considered to be impaired if the urges have become compulsory, if they produce sexual dysfunction, if they require the participa- tion of nonconsenting persons, if they lead to legal problems, or if they interfere with social relationships. For several specific types of paraphilic disorders, the person would qualify for a diagnosis if he acted on the urge (Hilliard & Spitzer, 2002). These include pedophilic, exhibitionistic, voyeuristic, and frotteuristic disorders (see descriptions in the following pages). For sexual sadism, act- ing on the urge would qualify the person for a diagnosis only if the partner had not consented to the activity. Acting on the other

that are associated with (1) nonhuman objects, (2) suffering or humiliation of oneself or one’s partner, or (3) children or other nonconsenting persons. According to DSM-5, there is an impor- tant distinction between a paraphilia and a paraphilic disorder. Paraphilia is a term that describes “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with a phenotypically normal, physi- cally mature, consenting human partner” (APA, 2013, p. 685). Paraphilic disorder is a term that describes a paraphilia that ei- ther leads to subjective distress or social impairment for the per- son or that causes harm to, or threatens, other people (Blanchard, 2010). This distinction indicates that some forms of nonnorma- tive sexual behaviors, such as fetishism and sexual masochism, are not necessarily pathological if they are practiced voluntarily by consenting adults (Wright, 2010).

In the following pages, we summarize a few of the most com- mon paraphilic disorders, and we consider some of the factors that might influence the development of unusual sexual preferences.

Symptoms One hundred years ago, many psychiatrists considered any type of sexual behavior other than heterosexual intercourse to be path- ological. Contemporary researchers and clinicians have expanded the boundaries of normal behavior to include a much broader range of sexual behavior. A large proportion of men and women engage in sexual fantasies and mutually consenting behaviors such as oral sex. These experiences enhance their relationships without causing problems (Herbenick, Reece, Schick, Sanders, Dodge, Fortenberry, 2010). Problems with sexual appetites arise when a pattern develops involving a long-standing, unusual erotic preoc- cupation that is highly arousing, coupled with a pressure to act on the erotic fantasy.

It is actually somewhat misleading, or imprecise, to say that paraphilic disorders are defined solely in terms of reactions to unusual stimuli. The central problem is that sexual arousal is dependent on images that are detached from reciprocal, lov- ing relationships with another adult (Levine, Risen, & Althof, 1990). Themes of aggression, violence, and hostility are com- mon in paraphilic fantasies, as are impulses involving strangers or unwilling partners. Rather than focusing on whether the stimuli are common or uncommon, some experts place principal empha- sis on the lack of human intimacy that is associated with many forms of paraphilias (Moser, 2001).

Compulsion and lack of flexibility are also important fea- tures of paraphilic behaviors. Paraphilias may take up a lot of time and consume much of the person’s energy. In that sense, they are similar to the addictions. People with paraphilic disor- ders are not simply aroused by unusual images or fantasies. They feel compelled to engage in certain acts that may be personally degrading or harmful to others, in spite of the fact that these ac- tions are often repulsive to others and are sometimes illegal. The following case describes some of the central features of paraphilic disorders.

334 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

forms of paraphilic urges (masochism, fetishism, and transvestic fetishism) would not be sufficient for a diagnosis unless the urges of fantasies lead to significant personal distress or interfere with the person’s ability to function.

Although they are listed as distinct disorders, it might be more useful to think of the paraphilic disorders as one diag- nostic category, with the specific forms listed in DSM-5 rep- resenting subtypes of this single disorder (Fedoroff, 2003). Differences among them are based on the focus of sexual inter- est (see Table 12.2). The primary types of paraphilic disorder described in the following pages are the ones most often seen in clinics that specialize in the treatment of sexual disorders. Not surprisingly, they are also the ones that frequently lead to a person being arrested. Other types of paraphilias are listed in Table 12.3.

table 12.3 Other Types of Paraphilias Name Focus of Sexual Urges and Fantasies

Telephone scatologia Obscene phone calls

Necrophilia Corpses

Partialism One specific part of the body

Zoophilia Animals

Coprophilia Feces

Klismaphilia Enemas

Urophilia Urine

Stigmatophilia Piercing; marking body; tattoos

table 12.2 Paraphilic Disorders Listed in DSM-5 ANOMALOUS ACTIVITY PREFERENCES

Courtship Disorders Focus of sexual interest

Voyeuristic Disorder spying on others in private activities

Exhibitionistic Disorder exposing genitals to non-consenting others

Frotteuristic Disorder touching or rubbing against non-consenting others

Sexual Arousal Associated with Pain

Sexual Sadism Disorder inflicting humiliation, bondage, or suffering

Sexual Masochism Disorder undergoing humiliation, bondage, or suffering

ANOMALOUS TARGET PREFERENCES

Directed at other humans Focus of sexual interest

Pedophilic Disorder pre-pubescent children

Directed elsewhere

Fetishistic Disorder non-living objects or highly specific focus on non-genital body parts

Transvestic Disorder cross-dressing

Source: Courtesy of Thomas F. Oltmanns and Robert E. Emery.

FETIShISTIC DISORDER Anthropologists use the word fetish to describe an object that is believed to have magical powers to pro- tect or help its owner. In psychopathology, fetishistic disorder is defined in terms of the association of sexual arousal with nonliv- ing objects. The range of objects that can become associated with sexual arousal is virtually unlimited, but fetishism most often in- volves women’s underwear, shoes and boots, or products made out of rubber or leather (Darcangelo, 2008). The person may go to great lengths, including burglary, to obtain certain kinds of fetish objects.

People who fit the description of fetishism typically mas- turbate while holding, rubbing, or smelling the fetish object.

Many men find women’s clothing attractive or sexy, but for a man with a fetish, sexual arousal is focused exclusively on the object. The partner is largely irrelevant.

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 335

masturbates while he is cross-dressed, often imagining himself to be a male as well as the female object of his own sexual fantasy. Aside from their interest in cross-dressing, men with transvestic disorder are unremarkably masculine in their interests, occupa- tions, and other behaviors. Most of these men get married and have children (Schott, 1995). For some men, transvestism may eventually lead to feelings of dissatisfaction with being male (Zucker & Blanchard, 1997). They may develop persistent dis- comfort with their gender role or identity and may eventually want to live permanently as women.

Sexual MaSocHiSM DiSoRDeR People who become sexu- ally aroused when they are subjected to pain or embarrassment are called masochists. DSM-5 defines sexual masochism dis- order in terms of recurrent, intense sexually arousing fantasies, urges, or impulses involving being humiliated, beaten, bound, or otherwise made to suffer (Hucker, 2008; Krueger, 2010). People who qualify for this diagnosis may act on these impulses by them- selves or with a partner. In some large cities, clubs cater to the sexual interests of masochistic men and women, who pay people to inflict pain on them.

The person may become aroused by being bound, blind- folded, spanked, pinched, whipped, verbally abused, forced to crawl and bark like a dog, or in some other way made to experi- ence pain or feelings of shame and disgrace. One relatively com- mon masochistic fantasy takes the form of being forced to display one’s naked body to other people. Masochists desire certain types of pain (which are carefully controlled to remain within speci- fied limits, usually unpleasant but not agonizing), but they also go to great lengths to avoid injury during their contrived, often ritualized experiences (Stoller, 1991). They do not enjoy, and are not immune to, painful experiences that lie outside these limited areas of their lives.

The following first-person account was written by Daphne Merkin (1996), an accomplished writer whose fascinating and controversial essay on masochism appeared in The New Yorker.

Sexual Masochism Disorder

The fact is that I cannot remember a time when I didn’t think about being spanked as a sexually gratifying act, didn’t fan- tasize about being reduced to a craven object of desire by a firm male hand. Depending on my mood, these daydreams were marked by an atmosphere of greater or lesser ravish- ment, but all of them featured similar ingredients. Most important among them was a heightened—and deeply plea- surable—sense of exposure, brought about by the fact that enormous attention was being paid to my bottom, and by the fact that there was an aspect of helpless display attached to this particular body part. This scenario, in which my normally alert self was reduced to a condition of wordless compliance via a specific ritual of chastisement, exerted a grip that was the more strong because I felt it to be so at odds with the intellectually weighty, morally upright part of me. (p. 99)

Particular sensory qualities of the object—texture, visual appear- ance, and smell—can be very important in determining whether the person finds it arousing. In addition to holding or rubbing the object, the person may wear, or ask his sexual partner to wear, the object during sexual activity. The person may be unable to become sexually aroused in the absence of the fetish object.

tRanSveStic DiSoRDeR A transvestite is a person who dresses in the clothing of the other gender. In DSM-5, transvestic disorder is defined as cross-dressing for the purpose of sexual arousal. It has been described primarily among heterosexual men and should not be confused with the behavior of some gay men known as drag queens (for whom cross-dressing has a very differ- ent purpose and meaning).

People who meet criteria for transvestic disorder usually keep a collection of female clothes that are used to cross-dress. Some wear only a single article of women’s clothing, such as female underwear, covered by male clothing. Others dress completely as women, including makeup, jewelry, and accessories. Cross- dressing may be done in public or only in private. The person

Some gay men who dress in women’s clothes refer to themselves as “drag queens.” This is different from transvestic fetishism, which applies only to heterosexual men whose cross-dressing is associated with intense, sexually arousing fantasies or urges.

336 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

Like Daphne Merkin, many people who engage in mas- ochistic sexual practices are highly educated and occupationally successful. Masochists tend to be disproportionately represented among the privileged groups in society. This pattern leads to the suggestion that masochism may be motivated by an attempt to escape temporarily from the otherwise constant burden of main- taining personal control and pursuing self-esteem (Baumeister & Butler, 1997).

Sexual SaDiSM DiSoRDeR Someone who derives pleasure by inflicting physical or mental pain on other people is called a sa- dist. The term is based on the writings of the Marquis de Sade, whose novels describe the use of torture and cruelty for erotic purposes. DSM-5 defines sexual sadism disorder in terms of in- tense, sexually arousing fantasies, urges, or behaviors that involve the psychological or physical suffering of a victim. Sadistic fanta- sies often involve asserting dominance over the victim; the experi- ence of power and control may be as important as inflicting pain (Hucker, 1997). Some people engage in sadistic sexual rituals with a consenting partner (who may be a sexual masochist) who willingly suffers pain or humiliation. Others act on sadistic sexual urges with nonconsenting partners. In some cases, the severity of the sadistic behaviors escalates over time.

exHiBitioniStic DiSoRDeR DSM-5 defines exhibitionistic disorder in terms of the following criteria: “(1) Over a period of at least six months, recurrent and intense sexual arousal from the exposure of one’s genitals to an unsuspecting person, as mani- fested by fantasies, urges, or behaviors. (2) The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 2013, p. 689). This behavior is also known as indecent exposure. Many different patterns of behavior fit into this category. About half of these men have erections while ex- posing themselves, and some masturbate at the time. The others

These fantasies and urges made Merkin feel uncomfortable, and she kept them to herself for many years. Being cautious and somewhat inhibited—certainly not prone to illicit sexual adventures—she worried about the boundaries of her masochis- tic desires. If she ever acted on them, where would she stop? And how would her partner respond? After many years of privately harboring masochistic sexual fantasies, Merkin finally described her fascination with spanking to a man whom she had been dat- ing for several months. She was in her late twenties at the time, and eventually married this man. The following paragraph de- scribes what happened after her admission:

He appeared delighted at the prospect of implementing my wishes, and so it was that I found myself in the position I had been dreaming of for years: thrust over a man’s knee, be- ing soundly spanked for some concocted misdeed. The sheer tactile stimulation of it—the chastening sting—would have been enough to arouse me, but there was also, at last, the heady sense of emotional release: I was and was not a child; was and was not being reduced; was and was not being forced into letting go; was and was not the one in control. I had fantasized about this event for so long that in the back of my mind there had always lurked the fear that its gratification would prove disappointing. I needn’t have worried; the real- ity of spanking, at least initially, was as good as the dream. (pp. 112–113)

Merkin tired of the spankings after she gave birth to her daughter, but the fantasies and urges returned several years later, after she had been separated from her husband. She eventu- ally became involved in a relationship with another man that she described as “a fairly conventional romance that included some light (sadism and masochism).” After their mutual interests and consenting activities had escalated, Merkin found the relationship disturbing:

It occurred to me that underneath my own limited partici- pation in this world I felt enormous resentment; I was fol- lowing the steps in a dance I couldn’t control. Spanking and its accoutrements may have helped to subdue my sim- mering rage toward men—as well as theirs toward me—but it also demonstrated how far I was from healthy intimacy, from the real give-and-take that makes a relationship vi- able. (p. 114)

This case illustrates the compelling and often contradictory nature of the fantasies that are associated with paraphilias. This successful and independent woman, who did not believe in using corporal punishment with her own daughter, found great plea- sure associated with fantasies of being spanked by a man. Mer- kin would not have qualified for a diagnosis of sexual masochism, even after she had acted on her fantasies, unless she experienced subjective distress or social impairment as a result.

MyPsychlab Video case

Exploring Sexual Sadism and Masochism

JOCELYN

“I really wanted to feel what it was like to be overpowered.”

Watch the Video Jocelyn: Exploring Sadism and Masochism on MyPsychLab

Do you think that voluntary sexual activities performed with a consenting partner should be considered symptoms of a disorder? In what ways could these behaviors be considered harmful to the person’s life (other than the experience of pain)?

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 337

The frotteur usually chooses crowded places, such as sidewalks and public transportation, so that he can easily escape arrest. He either rubs his genitals against the victim’s thighs and buttocks or fondles her genitalia or breasts (Horley, 2001; Lussier & Piché, 2008).

Like exhibitionism, frotteurism is a high-frequency form of paraphilic disorder; interviews with people being treated for frot- teurism indicate that they may engage in hundreds of individual paraphilic acts. People who engage in frotteurism seek to escape as quickly as possible after touching or rubbing against the other person. They do not want further sexual contact.

PeDoPHilic DiSoRDeR People who persistently engage in sexual activities with children exhibit what is undoubtedly the most alarming and objectionable form of paraphilic behavior: pe- dophilia. Every year, more than 100,000 children in the United States are referred to child protective services because of sus- pected child abuse (see Chapter 18). The effects of child abuse on victims have been the subject of intense debate in recent years. Some victims later engage in excessive and risky sexual activities that lead to additional problems (Browning & Laumann, 1997). One controversial review concluded that negative consequences are neither pervasive nor typically intense (Rind, Tromovitch, & Bauserman, 1998). We must be cautious, however, about ac- cepting the null hypothesis (see Research Methods in Chapter 1). Failure to detect significant differences between victims of abuse and other people may indicate that investigators have not exam- ined the appropriate dependent measures. Harmful consequences of sexual abuse may take many forms, including the disruption of future relationships and discomfort with sexual activity (Emery & Laumann-Billings, 1998). Other forms of mental disorder, such as PTSD and eating disorders, can also be the product of prior sexual abuse (see Chapters 7 and 10).

Pedophilic disorder entails recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child (generally age 13 years or younger). In order to qualify for a diagnosis of pedophilia in DSM-5, the person must be at least 16 years of age and at least five years older than the child. The terms pedophile and child molester are sometimes used interchangeably, but this practice confuses legal definitions with psychopathology. A child molester is a person who has committed a sexual offense against a child victim. Therefore, the term depends on legal definitions of “sex- ual offense” and “child victim,” which can vary from one state or country to another. In many locations, a child might be anyone under the age of consent, even if that person has reached puberty. All child molesters are not pedophiles. Furthermore, some pedo- philes may not have molested children, because the diagnosis can be made on the basis of recurrent fantasies in the absence of ac- tual behavior, if those fantasies cause marked distress or interper- sonal difficulty (Barbaree & Seto, 1997).

Pedophilia includes a great variety of behaviors and sexual preferences (Cohen & Galynker, 2002; Fagan, Wise, Schmidt,

usually masturbate shortly after the experience while fantasizing about the victim’s reaction. Their intent usually involves a de- sire to shock the observer, but sometimes they harbor fantasies that the involuntary observer will become sexually aroused. They rarely attempt to touch or otherwise molest their victims, who are usually women or children (Murphy & Page, 2008).

Exhibitionistic disorder is almost exclusively a male disor- der. Most exhibitionists begin to expose themselves when they are teenagers or in their early twenties. As adults, most are either married or living with a sexual partner. Exhibitionism is seldom an isolated behavior; men who engage in this type of behavior tend to do it frequently (Abel & Osborn, 1992).

voYeuRiStic DiSoRDeR The focus of sexual arousal in voyeuristic disorder is the act of observing an unsuspect- ing person, usually a stranger, who is naked, in the process of disrobing, or engaging in sexual activity (Metzl, 2004). Many people, especially men, are sexually aroused by the sight of peo- ple who are partially clad or naked. Voyeurs are not aroused by watching people who know that they are being observed. The process of looking (“peeping”) is arousing in its own right. The person might fantasize about having a sexual relationship with the people who are being observed, but direct contact is sel- dom sought. In fact, the secret nature of the observation and the risk of discovery may contribute in an important way to the arousing nature of the situation. The voyeur reaches orgasm by masturbating during observation or later while remembering what he saw. Most keep their distance from the victim and are not dangerous, but there are exceptions to this rule (Långström, 2010).

FRotteuRiStic DiSoRDeR In frotteuristic disorder, a per- son who is fully clothed becomes sexually aroused by touching or rubbing his genitals against other, nonconsenting people.

To protect women from frotteurs, some railway companies in Japan set aside special women-only cars during peak hours and late at night. This sign in a Tokyo subway station says, “Beware of men who fondle women on crowded trains.”

338 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

forced sex, 30 percent said that they had been forced sexually by more than one person.

Some rapes are committed by strangers, but many others— known as acquaintance rapes—are committed by men who know their victims. Most female victims know the person who raped them (Wiehe & Richards, 1995). Consider, for example, evidence from women in the NHSLS who had been victims of forced sex. Their relationship to the people who forced them to have sex is illustrated in Figure 12.4. Most reported that the person was either someone with whom they were in love or their spouse. Only 4 percent were forced to do something sexual by a stranger.

Rapes are committed by many different kinds of people for many different reasons (Bachar & Koss, 2001). The feminist per- spective on rape emphasizes male aggression and violence. The traditional clinical perspective has been concerned with sexual deviance. The authors of DSM-5 considered including rape as a type of paraphilia, but the proposal was rejected (see Think- ing Critically About DSM-5). Nevertheless, the behavior of some rapists does include essential features of paraphilias: recurrent, in- tense sexually arousing fantasies and urges that involve the suffer- ing of nonconsenting persons.

Efforts to classify sexual offenders have attempted to distin- guish between those for whom deviant sexual arousal contrib- utes to the act and those whose behavior is motivated primarily by anger or violent impulses. One interesting set of results was produced by studying convicted rapists who were imprisoned at an institution for sexually dangerous persons (Knight & Guay, 2006). Four different types of rapists were identified. Two catego- ries include men whose motivation for sexual assault is primar- ily sexual in nature. Sadistic rapists exhibit features that are close to the generic DSM-5 definition of a paraphilic disorder. Their

Berlin, 2002). Some pedophiles are attracted only to children, whereas others are sometimes attracted to adults. Most pedo- philes are heterosexual, and the victims of pedophilia are more of- ten girls than boys. Some offenders are attracted to both girls and boys. Sexual contact with children typically involves caressing and genital fondling. Vaginal, oral, and anal penetration are less common, and physical violence is relatively rare. In many cases, the child willingly and naively complies with the adult’s inten- tions. In most cases, the child knows the person who molests him or her. More than half of all offenses occur in the home of either the child or the offender.

Incestuous relationships, in which the pedophile molests his own children, should perhaps be distinguished from those in which the offender is only casually acquainted with the victim. Incest refers to sexual activity between close blood relatives, such as father–daughter, mother–son, or between siblings. The defini- tion may also be expanded to include stepchildren and their step- parents in reconstituted families. Most reported cases of incest involve fathers and stepfathers sexually abusing daughters and stepdaughters (Cole, 1992).

Many incest perpetrators would not be considered pedo- philes, either because their victims are postpubescent adolescents or because they are also young themselves (such as male adoles- cents molesting their younger sisters). Perhaps as many as half of the men who commit incest have also engaged in sexual activity with children outside their own families (Abel & Osborn, 1992). This subgroup of pedophilic incest perpetrators may be the most harmful and the most difficult to treat. Their personality style is typically passive and dependent. They are unable to empathize with the plight of their victims, perhaps in part because they were absent or uninvolved in early childcare responsibilities (Williams & Finkelhor, 1990).

RaPe anD Sexual aSSault The legal definition of rape includes “acts involving nonconsensual sexual penetration ob- tained by physical force, by threat of bodily harm, or when the victim is incapable of giving consent by virtue of mental illness, mental retardation, or intoxication” (Goodman, Koss, & Russo, 1993). One conservative estimate of rape prevalence based on a national survey indicated that 14 percent of adult women had been raped (National Victim Center, 1992). The actual rate is probably higher, perhaps in the vicinity of 20 percent (Watts & Zimmerman, 2002). The impact of sexual assault on the victim is described in Chapter 7.

The frequency of coercive sex was studied as part of the NHSLS (Laumann, Gagnon, Michael, Michaels, 1994). The 3,500 participants were asked whether they had ever been forced to do something sexually that they did not want to do. The ques- tion was focused broadly and did not necessarily focus only on acts involving penetration or threats of violence. Slightly more than one out of every five women in the sample reported that they had been forced by a man to engage in some kind of sexual activ- ity against their will. Among those women who had experienced

figure 12.4 Forced Sex: Relationship of Perpetrator to victim As this chart shows, most NHSLS respondents who were forced into sexual activity knew the person who coerced them. Source: Based on Laumann, Edward O., John H. Gagnon, Robert T. Michael and Stuart Michaels. 1994. The Social Organization of Sexuality: Sexual Practices in the United States. University of Chicago Press.

Someone with whom victim was in love

46%

Someone victim

knew well 22%

Acquaintance 19%

Stranger 4% Spouse

9%

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 339

Thinking cRiTically about dsM-5

Two Sexual Problems That Did Not Become New Mental Disorders

When we evaluate DSM-5 critically, it’s important to con-sider disorders that are not included in the manual as well as those that are. Both domains help us appreciate the thinking that shaped DSM-5. The popular media are fasci- nated by wild ideas about various kinds of behavior that some- one considers to be abnormal and therefore a sign of mental disorder. Many proposals for new disorders were developed and evaluated by DSM-5 workgroups. A few were added to the new manual, and several were ultimately rejected. Two involved sexual behaviors: hypersexual disorder and paraphilic coercion disorder.

DSM-5 includes unusually low sexual desire as a male sexual dys- function, but it does not mention unusually high sexual desire. Symptoms associated with this condition presumably include behaviors such as seeking new sexual encounters out of bore- dom with old ones and frequent use of pornography. Additional features include obsessive thoughts about sexual encounters, guilt resulting from problematic sexual behavior, and rational- ization for continued reckless sexual behavior. Reckless and uncontrolled sexual activity can obviously disrupt a person’s life and cause significant personal distress. Some experts wanted hypersexual behavior to be added to DSM-5 (Kafka, 2010). They view uncontrolled sexual behavior as being similar to an addiction (Bancroft & Vukadinovic, 2004).

There are several good reasons to be skeptical of this concept. Perhaps most important is the heterogeneous nature of exces- sive or uncontrolled sexual behavior. Failure to control sexual impulses can be associated with several other disorders, includ- ing paraphilic disorders, impulse control disorders, and bipolar disorder (Levine, 2010). Many people who admit to compulsive sexual behavior also suffer from major depression, anxiety disor- ders, and substance use disorders (Black, Kehrberg, Flumerfelt, Schlosser, 1997; Guiliano, 2009). The concept obviously includes a diverse set of behavioral problems. It also suffers from con- ceptual problems that have been raised with regard to impulse control disorders (see page 252 in Chapter 9) and behavioral addictions (see Thinking Critically About DSM-5 in Chapter 11). For all of these reasons, the proposal for recognizing hypersex- ual disorder as a new diagnosis in DSM-5 was rejected.

The DSM-5 workgroup also tackled a long-standing controversy regarding mental disorders and sexual assault. Do rapists suffer from a paraphilic disorder? The workgroup considered a new diagnostic category to be called paraphilic coercive disorder or PCD (Thornton, 2010). This proposal was grounded in the

recognition that, for most men, sexual arousal is inhibited by obvious clues that their partner is feeling coerced. The new diagnosis would have applied to the minority of men for whom the opposite pattern is observed and coercion actually leads to increased sexual arousal. Sexual predator laws allow for invol- untary commitment of those people who are judged to have a mental abnormality that would lead them to commit further of- fenses. PCD would be one option for this diagnostic decision.

Several problems are associated with the diagnosis of PCD (Wakefield, 2012). One is that paraphilic disorders are defined in terms of recurrent, intense sexually arousing fantasies or sexual urges focused on non-normative activities or targets, in this case sexual coercion. Fantasies and urges are obviously private ex- periences. In a criminal setting, alleged perpetrators may refuse to cooperate with assessments aimed at the identification of these subjective signs. It would then be tempting to diagnose paraphilic coercion disorder on the basis of the man’s behavior (e.g., he raped several people, so he must be aroused by sexual coercion). But there would be no way to differentiate true cases of PCD from men who rape for other reasons, and the former outnumber the latter by a large margin. Furthermore, it is not clear that this syndrome can be distinguished reliably from more general sadistic urges and fantasies (Knight, 2010). For all of these reasons, the proposal to add PCD to DSM-5 was rejected. As one critique noted: “Rape is a crime, and prison is the proper placement for rapists” (Tucker & Brakel, 2012).

Why were these proposals rejected while others were accepted? Maybe it’s because they are problems that affect primarily men rather than women (cf. binge eating, premenstrual dysphoria), but we doubt it. You could also wonder if it’s because both problems may be relatively rare, and the new diagnostic catego- ries would not create huge new markets for the pharmaceuti- cal industry. We also doubt that. We think the proposals were rejected because experts considered the evidence carefully and reached the correct decision in both cases.

Public criticism of DSM-5 has often focused on expansion of the manual to include new diagnostic categories. Reviewers have ar- gued that “normality is threatened” because so many people may now qualify for a diagnosis. There is certainly some merit to these arguments, but the cases of hypersexual disorder and paraphilic coercive disorder put the other additions in perspective. The work- groups did, in fact, reject a number of proposals, and their decisions were based on thoughtful consideration of the relevant evidence.

behavior is determined by a combination of sexual and aggressive impulses. The nonsadistic category also includes men who are pre- occupied with sexual fantasies, but these fantasies are not blended with images of violence and aggression. The sexual aggression of

these men may result, in part, from serious deficits in the ability to process social cues, such as the intentions of women.

The other two categories describe men whose primary mo- tivation for rape is not sexual. Vindictive rapists seem intent on

340 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

(Langevin, 1992). These reports must be viewed with some skep- ticism, however, for two reasons. First, the participants in these studies are invariably convicted sexual offenders. Thus, it is not clear that the findings can be generalized to all people with para- philic disorders. Second, there is a high rate of alcoholism and drug abuse among men convicted of sexual crimes. For that rea- son, we do not know whether the biological abnormalities ob- served in these men are causes of their deviant sexual behavior or consequences of prolonged substance abuse.

Neurological abnormalities may also be involved in the de- velopment of paraphilic disorders. Structures located in the temporal lobes of the brain, especially the amygdala and the hip- pocampus, appear to play an important role in the control of both aggression and sexual behavior. These limbic structures, in conjunction with the hypothalamus, form a circuit that regulates biologically significant behaviors that sometimes are whimsically called the four Fs—feeding, fighting, fleeing, and [fornication] (Valenstein, 1973). In 1937, two scientists reported that after ex- tensive bilateral damage to their temporal lobes, rhesus monkeys showed a dramatic increase in sexual activity, as well as a number of related behavioral and perceptual abnormalities. The monkeys apparently tried to copulate with a variety of inappropriate part- ners, including the investigators. This pattern has subsequently been called the Klüver–Bucy syndrome, named after the scientists who made the original observation.

Inspired by the suggestion that damage to the temporal lobe can lead to unusual patterns of sexual behavior, clinical scientists have studied a number of neurological and neuropsychological factors in convicted sex offenders. Some reports indicate that men with pedophilic disorder and exhibitionistic disorder show subtle forms of left temporal lobe dysfunction, as evidenced by abnor- mal patterns of electrophysiological response and impaired per- formance on neuropsychological tests (Bradford, 2001; Murphy, 1997).

Social FactoRS Some types of paraphilias seem to be distor- tions of the normal mating process when viewed in a broad, evo- lutionary context. For male primates, sexual behavior involves a sequence of steps: location and appraisal of potential partners; ex- change of signals in which partners communicate mutual interest; and tactile interactions that set the stage for sexual intercourse. Voyeurism, exhibitionism, and frotteurism may represent aber- rant versions of these social processes. Therefore, some types of paraphilic disorder have been described as “courtship disorders” (Freund & Blanchard, 1993; Freund & Seto, 1998). Something has apparently gone wrong, disrupting whatever mechanisms facilitate the identification of a sexual partner and govern behaviors used to attract a partner.

If people with some forms of paraphilic disorder have some- how failed to learn more adaptive forms of courtship behavior, what sort of childhood experiences might have produced such unexpected results? Several background factors have been ob- served repeatedly among people who engage in atypical sexual

violence directed exclusively toward women. Their aggression is not erotically motivated, as with sadistic rapists. Opportunistic rapists are men with an extensive history of impulsive behavior in many kinds of settings and who might be considered psycho- paths (see Chapter 9). Their sexual behavior is governed largely by immediate environmental cues. They will use whatever force is necessary to ensure compliance, but they express anger only in re- sponse to the victim’s resistance. This research program confirms the impression that sex offenders are, in fact, an extremely hetero- geneous group (McCabe & Wauchope, 2005).

Frequency There is very little evidence regarding the frequency of various types of unconventional sexual behavior. This is especially true for victimless or noncoercive forms of paraphilia, such as fetish- ism, transvestism, and sexual masochism, because most of these people seldom seek treatment or come to the attention of law enforcement officials. Furthermore, the fact that these forms of behavior are considered deviant or perverse makes it unlikely that people who engage in them will readily divulge their secret urges and fantasies.

With the exception of sexual masochism, paraphilias are al- most always male behaviors. Some 95 percent of the people who seek treatment for paraphilic disorders are men. Paraphilias are seldom isolated phenomena. People who exhibit one type of para- philia often exhibit others (Marshall, 2007). Gosselin and Wilson (1980) surveyed men who belonged to private clubs that cater to fetishists, sadomasochists, and transvestites, and they found that the members of different clubs often shared the same inter- ests. This pattern has been called crossing of paraphilic behaviors. There is obviously a considerable amount of crossover among paraphilias.

causes The high rate of overlap among paraphilias indicates that the eti- ology of these interests and behaviors might be most appropri- ately viewed in terms of common factors rather than in terms of distinct pathways that lead exclusively to one form of paraphilia or another. Those experiences and conditions that predispose an individual to one form of paraphilic disorder are apparently also likely to lead to another. In the following pages, we review a number of proposals regarding the etiology of paraphilic dis- orders. Some of these have been associated with specific types of paraphilias. For the most part, however, they are concerned more generally with many forms of paraphilias.

BioloGical FactoRS Most of the research regarding the role of biological factors in the etiology of paraphilic disorders has fo- cused on the endocrine system (see Figure 2.4 on page 38), the collection of glands that regulate sexual responses through the release of hormones. Some studies of convicted sexually violent offenders have found evidence of elevated levels of testosterone

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 341

solution to this dilemma would be to avoid or deny sexual ex- pression altogether. That might explain the development of lack of sexual desire. Sexual impulses are powerful, however, and they are not easily denied. In some cases, they are rerouted rather than being shut off completely. Various types of paraphilias represent alternative strategies through which the person finds it possible to express sexual feelings outside an intimate, loving relationship with another adult. Exhibitionism, voyeurism, and fetishism, therefore, are partial solutions to the perceived incompatibility of love and lust.

treatment The treatment of paraphilic disorders is different from the treat- ment of sexual dysfunctions in several ways. Perhaps most impor- tant is the fact that most people with paraphilic disorders do not enter treatment voluntarily. They are often referred to a therapist by the criminal justice system after they have been arrested for exposing themselves, peeping through windows, or engaging in sexual behaviors with children. Their motivation to change is, therefore, open to question. Participation in treatment may help them receive reduced sentences or avoid other legal penalties. In many cases, they are being asked to abandon highly reinforcing behaviors in which they have engaged for many years. Their fami- lies and other members of society may be much more concerned about change than they are. We mention this issue at the begin- ning of our discussion because the results of outcome studies in this area are typically less positive than are those concerning the treatment of sexual dysfunctions (McConaghy, 1999; Prentky, Lee, Knight, Cerce, 1997).

aveRSion tHeRaPY For several decades, the most commonly used form of treatment for paraphilic disorders was aversion therapy. In this procedure, the therapist repeatedly presents the stimulus that elicits inappropriate sexual arousal—such as slides of nude children—in association with an aversive stimulus, such as repulsive smells, electric shock, or chemically induced nausea. Revolting cognitive images are sometimes used instead of tangible aversive stimuli. Whatever the exact procedure, the rationale is to create a new association with the inappropriate stimulus so that the stimulus will no longer elicit sexual arousal. Some studies sug- gested that aversion therapy produces positive effects (Kilmann, Sabalis, Gearing II, Bukstel, Scovern, 1982). This treatment eventually fell into disfavor, however, because the studies that were used to evaluate it suffered from design flaws.

coGnitive BeHavioRal tReatMent Behavioral treatment programs for paraphilic disorders reflect a broader view of the etiology of these conditions. There is considerable reason to be- lieve that paraphilic disorders are based on a variety of cognitive and social deficits. Marshall, Eccles, and Barbaree (1991) com- pared two approaches to the treatment of exhibitionists. One was based on aversion therapy and the other employed cognitive

behaviors (Seto & Barbaree, 2000; Wincze, 1989). These include the following:

• Early crossing of normative sexual boundaries through a di- rect experience (for example, sexual abuse by an adult) or an indirect experience (hearing about a father’s atypical sexual behavior)

• Lack of a consistent parental environment in which norma- tive sexual behavior and values were modeled

• Lack of self-esteem

• Lack of confidence and ability in social interactions

• Ignorance and poor understanding of human sexuality

All these factors may increase the probability that a person might experiment with unusual types of sexual stimulation or employ maladaptive sexual behaviors.

Although the most notable feature of paraphilias is sexual arousal, ultimately the paraphilic disorders are problems in social relationships. Interpersonal skills may, therefore, play as impor- tant a role as sexual arousal. The core feature of unusual sexual behavior may be a failure to achieve intimacy in relationships with other adults (Marshall, 1989; Seidman, Marshall, Hudson, Robertson, 1994). According to this perspective, people with paraphilic disorders are lonely, insecure, and isolated and have sig- nificant deficits in social skills. Offensive sexual behaviors, such as those observed in pedophilic disorders, are maladaptive attempts to achieve intimacy through sex. These efforts are invariably un- successful and self-defeating in the sense that they serve to isolate the person further from the rest of the community. Paradoxically, the pattern may become deeply ingrained because it results in the momentary pleasure associated with orgasm and because it offers the illusory hope of eventually achieving intimacy with another person.

PSYcHoloGical FactoRS Another influential perspective on the development of paraphilias has used a geographic meta- phor known as a lovemap (Money, 2002). A lovemap is a mental picture representing a person’s ideal sexual relationship. It might also be viewed as the software that encodes his or her sexual fan- tasies and preferred sexual practices. These “programs” are written early in life, and they are quite persistent. Children learn their lovemaps during sexual play, by imitation of their parents and other adults, and through messages that they digest from the pop- ular media. According to this theory, when optimal conditions prevail, the child develops a lovemap that includes intercourse as a preferred form of sexual expression. The child learns that love— romantic attachment to another adult—and lust—erotic attrac- tion—can be directed toward the same person.

The lovemap can be distorted, according to this metaphor, if the child learns that romantic attachment and sexual desire are incompatible—that these feelings cannot be directed toward the same person. The inability to integrate these aspects of the lovemap lies at the heart of this explanation for paraphilias. One

342 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

volunteered to participate in the program but were assigned to a no-treatment control group (Marques, 1999). Within four years after their release from prison, the percentage of men who were arrested for another sexual offense was essentially identical to that of the men who had been treated and of those in the control group (13 percent). The rate of arrest for subsequent violent of- fenses was somewhat lower for the treatment group than for the controls, but the difference was not significant.

Results were somewhat more encouraging with men con- victed of rape than with those who had molested children. Nev- ertheless, the data from this study are discouraging. They suggest that a broadly based behavioral program focused on education, social skills, and relapse prevention procedures does not lead to obviously better outcomes than a routine period of incarceration (Maletzky, 2002).

hORMONES AND MEDICATION Another approach to the treatment of paraphilic disorders involves the use of drugs that reduce levels of testosterone, on the assumption that male hor- mones control the sexual appetite (Hill, Briken, Kraus, Strohm, Berner, 2003). One study reported that treatment of paraphilic men with cyproterone acetate, a drug that blocks the effects of testosterone, produced a significant reduction in some aspects of sexual behavior, especially sexual fantasies (Bradford & Paw- lak, 1993). Among men with pedophilic disorder, the study found a greater reduction of sexual fantasies of children than of images of sex between consenting adults. Positive results have also been reported for use of triptorelin, which reduces testos- terone secretion by inhibiting pituitary–gonadal function. In an uncontrolled trial, 30 male patients (25 with pedophilia) received monthly injections of triptorelin as well as supportive psychotherapy. All of the patients showed a reduction in deviant fantasies and in the number of incidents of paraphilic behav- iors (Rosler & Witztum, 1998). We must remember, however, that the absence of double-blind, placebo-controlled studies leaves the efficacy of these drugs in doubt. One review of this literature concludes that treatment programs should never rely exclusively on the use of medications that reduce levels of tes- tosterone (Prentky, 1997).

Antidepressants and antianxiety drugs have also been used to treat paraphilic disorders. Some outcome studies indicate that the SSRIs can have beneficial effects for some male patients (Thibaut, De LaBarra, Gordon, Cosyns, Bradford, 2010). The process by which these drugs manage to alter sexual behavior is open to question. For example, medication may work directly by decreasing deviant sexual interests without affecting other forms of sexual arousal. On the other hand, SSRIs may work by reduc- ing social anxiety, which interferes with the ability to enjoy an intimate sexual relationship with another adult.

LEGAL ISSUES The U.S. Congress and all 50 states have passed laws that are intended to protect society from people who have

restructuring, social skills training, and stress management proce- dures. The men who received the second type of treatment were much less likely to return to their deviant forms of sexual behav- ior than were the men who received aversion therapy. Treatment with aversion therapy was no more effective than was treatment with a placebo. These data suggest that broad-based cognitive and social treatment procedures may be most useful in the treatment of paraphilic disorders (Marshall, Bryce, Hudson, Ward, Moth, 1996).

Unfortunately, research results regarding the effectiveness of psychological treatment for sexual offenders are discouraging. The only large-scale evaluation of such programs that has em- ployed random assignment to treatment conditions is Califor- nia’s Sex Offender Treatment and Evaluation Project (SOTEP; Marques, Day, Nelson, West, 1993), which was designed for men convicted of either rape or child molestation. Men selected for this comprehensive treatment program were transferred to a spe- cial hospital unit, where they remained for several months. They received education in human sexuality as well as cognitive behav- ior therapy, including applied relaxation and social skills train- ing and stress and anger management. Treatment also included a relapse prevention component that was based on procedures used in the treatment of alcoholism (see Chapter 11). Relapse preven- tion procedures helped the men confront personal, social, and sexual difficulties that may increase their risk of relapse after they were released from prison.

The men in the treatment group were compared to those in two control groups. Outcome was measured in several ways, but the most important consideration was being arrested again for similar crimes. Figure 12.5 illustrates some of the results from this study, highlighting the comparison between 138 men who completed the treatment and 184 men who had originally

figure 12.5 Outcome of Psychological Treatment for Sex Offenders Repeat arrest rates among male sex offenders (4 years after treatment). Source: Based on Marques. J.K. How to Answer the Question: Does Sex Offender Treatment Work? Journal of Interpersonal Violence. 1999; 14: 437–451.

Pe rc

en t a

rr es

te d

af te

r r el

ea se

Completed Treatment

Sexual Offense

0

14

12

10

8

6

4

2

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Untreated Controls

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 343

Gender Dysphoria Our sense of ourselves as being either male or female is known as gender identity. Gender identity almost always reflects the child’s physical anatomy: Toddlers who possess a penis learn that they are boys, and those with a vagina learn that they are girls. Gender identity is usually fixed by the time a child reaches two or three years of age (Clemans, DeRose, Graber, Brooks-Gunn, 2010).

Gender identity must be distinguished from sex roles, which are characteristics, behaviors, and skills that are defined within a specific culture as being either masculine or feminine. For example, certain aspects of appearance and behavior are more often associated with men than with women. These are considered to be masculine. Those behaviors and appearances that are more often associated with women are considered feminine. In our own culture, masculine and feminine sex roles have changed considerably in recent years, and they overlap to a degree (Sczesny, Bosak, Diekman, Twenge, 2008).

Symptoms Some people are firmly convinced that their anatomy and their gender identity do not match up. In males, this means that they feel strongly that they are women trapped in a man’s body. For females, the opposite pattern holds. DSM-5 categorizes this sense of discomfort with one’s anatomical sex as gender dys- phoria. It has also been called transsexualism. People with gender dysphoria do not literally believe that they are members of the other gender. Rather, they feel that, with the exception of their physical anatomy, they are more like the other gender (Becker & Johnson, 2009).

Most transsexuals report that they were aware of these feel- ings very early in childhood. Many report that they dressed in

been convicted of violent or repeated sexual offenses. These laws fall into two categories. The first includes community notification laws (such as “Megan’s Law”), which require the distribution of information to the public regarding the presence of child molest- ers and sexually violent offenders when they are released from prison or placed on parole. These laws are based on two assump- tions: (1) Notification will reduce the offender’s opportunities to commit further crimes, and (2) citizens are better able to protect themselves and their children if they know that a dangerous per- son lives in their neighborhood. Critics of community notification laws argue that they violate the former offender’s constitutional rights by imposing an additional, unfair penalty after his sentence has been served. These laws are popular, but their impact has not been evaluated. It is not clear that people are actually better able to protect themselves after they have been notified. Furthermore, we do not know whether relapse rates are lower among sexual offend- ers who live in communities where such laws are strictly enforced (Edwards & Hensley, 2001; Younglove & Vitello, 2003).

The second category includes sexual predator laws, which are designed to keep some criminals in custody indefinitely. For ex- ample, a Kansas law passed in 1994 and later upheld by the U.S. Supreme Court permits authorities to commit certain sex offend- ers to a mental hospital after their prison terms are over. Each case is evaluated in a series of steps that end with a civil trial. The per- son can be hospitalized involuntarily and for an indefinite period of time if the jury decides the person has a “mental abnormality” that will lead him to commit further sexual offenses. Involuntary civil commitment is an infrequent outcome of this law (Fabian, 2011). When it does occur, however, serious questions are raised about the need to balance public safety against the protection of the offender’s constitutional rights (see the discussion of civil commitment in Chapter 18).

U.S. sex offenders can now be tracked on a radar-like app for the iPhone as glowing red dots in the Sex Offender Tracker. Under American law sex offenders must register in their local neighborhoods, and they will now be even more visible as tiny dots on a green screen. The military style radar app will, according to its makers, track sex-offenders in real-time as well as reveal detailed information of their location.

Caster Semenya, a track star from South Africa, was subjected to gender testing after she won the 800 meter world championship. Her body has external female characteristics and internal male characteristics, resulting in high levels of testosterone. She was later cleared to compete as a fe- male in the Olympic Games. Her case illustrates the important point that no single indicator—genes, hormones, or external appearance—can be used as an absolute indicator to distinguish between the sexes.

344 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

gender dysphoria is also poorly understood (Richmond, Carroll, & Denboske, 2010). There is some reason to believe that gender identity is strongly influenced by sex hormones, especially during the prenatal period (Diamond, 2009). Much of the research in this area has been done with animals, but an interesting set of data comes from studies of people with a condition that is sometimes called pseudohermaphroditism. Individuals with this condition are genetically male, but they are unable to produce a hormone that is responsible for shaping the penis and scrotum in the fe- tus. Therefore, the child is born with external genitalia that are ambiguous in appearance—thus the term pseudohermaphrodite.2

Many of these children are raised as girls by their families. When they reach puberty, a sudden increase in testosterone leads to dramatic changes in the appearance of the adolescent’s genitals. The organ that had previously looked more like a clitoris becomes enlarged and turns into a penis, and testicles descend into a scro- tum. The child’s voice becomes deeper, muscle mass increases, and the child quickly begins to consider himself to be a man. The speed and apparent ease with which people with these conditions

2A hermaphrodite has both male and female reproductive organs.

clothing and adopted sex-role behaviors of the other gender dur- ing childhood and adolescence. The intensity of the person’s discomfort varies from one individual to the next. Invariably, it becomes more intense during adolescence, when the person develops secondary sexual characteristics, such as breasts and wider hips for girls, and facial hair, voice changes, and increased muscle mass for boys. These characteristics make it more diffi- cult for a person to pass for the other gender. Many transsexuals become preoccupied with the desire to change their anatomical sex through surgical procedures (Paap, Kreukels, Cohen-Kettenis, Richter-Appelt, de Cuypere, Haraldsen, 2011).

Gender dysphoria should be distinguished from transves- tic disorder, discussed earlier, which is a form of paraphilia in which a man dresses in the clothing of the other gender in order to achieve sexual arousal. These are, in fact, very different condi- tions. Transvestites do not consider themselves to be women, and transsexuals are not sexually aroused by cross-dressing. They dress as women to feel more comfortable about themselves.

The relation between gender dysphoria and sexual orienta- tion has been a matter of some controversy. Some clinicians have suggested that transsexuals are homosexuals who claim to be members of the other gender as a way to avoid cultural and moral sanctions that discourage sexual relationships with members of their own sex. This proposal doesn’t make sense for two reasons. First, lesbians and gay men are not uncomfortable with their own gender identity. This observation suggests that transsexuals are not simply escaping the stigma of homosexuality. Second, labo- ratory studies suggest that transsexual and homosexual subjects exhibit different patterns of sexual arousal in response to erotic stimuli.

Frequency Gender dysphoria is rare in comparison to most of the other disorders that we have considered in this book. Male-to-female transsexuals are apparently more common than female-to-male transsexuals, at least based on the numbers of people who seek treatment at clinics. Some studies estimate the prevalence to be approximately one person with gender dysphoria for every 12,000 males and 30,000 females (Olsson & Moller, 2003).

Deeply ingrained cross-gender behaviors and attitudes among children occur infrequently in the general population. Mild forms of cross-gender behavior, such as dressing up in the clothes of the other gender or expressing a desire to be a mem- ber of the other sex, are relatively common during the preschool years. Extreme forms of these behaviors are relatively rare, how- ever, especially among boys (Zucker, 2009).

causes Very little is known about the origins of gender identity in nor- mal men and women, so it is not surprising that the etiology of

Jazz was a 6-year-old male-to-female transgender child when he and his family appeared on the television news program 20/20. When Jazz was 2 years old, if his parents praised him as a “good boy,” he would correct them, saying he was a good girl.

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 345

adopt a masculine gender identity suggest that their brains had been prenatally programmed for this alternative (Hines, 2004).

treatment There are two obvious solutions to problems of gender dyspho- ria: Change the person’s identity to match his or her anatomy, or

MyPsychlab Video case

Gender Identity Disorder

TRAVIS

“I was masculine, and that’s all that mattered. They were going to call me ‘he,’ and that was the end of the story. I felt free to be me. To just walk down the street with my shoulders up and just feel good about myself.”

Watch the Video Travis: Gender Dysphoria on MyPsychLab

change the anatomy to match the person’s gender identity. Vari- ous forms of psychotherapy have been used in an effort to alter gender identity, but the results have been fairly negative.

One alternative to psychological treatment is sex-reassignment surgery, in which the person’s genitals are changed to match the gender identity (Sohn & Bosinski, 2007). Medical science can construct artificial male and female genitalia. The artificial penis is not capable of becoming erect in response to sexual stimulation, but structural implants can be used to obtain rigid- ity. These surgical procedures have been used with thousands of patients over the past 50 or 60 years. Clinics that perform these operations employ stringent selection procedures, and pa- tients are typically required to live for several months as a mem- ber of the other gender before they can undergo the surgical procedure.

The results of sex-reassignment surgery have generally been positive (Johansson, Sundbom, Höjerback, Bodlund , 2010). In- terviews with patients who have undergone surgery indicate that most are satisfied with the results, and the vast majority believe that they do not have trouble passing as a member of their newly assumed gender. Psychological tests obtained from patients who have completed surgery indicate reduced levels of anxiety and depression.

getting helP

Many sexual problems can be traced to the absence of in-formation regarding the nature of sexual attitudes, feel-ings, preferences, and behaviors. Fortunately, access to these data, as well as public attitudes toward their discussion, has improved dramatically in recent years. The Sexuality Information and Education Council of the United States (SIECUS) collects and disseminates information and promotes education about sexual- ity. The council’s Internet homepage (www.siecus.org) contains an extensive list of resources, including books and links to other web- sites, dealing with topics that range from reproduction, women’s health, gender identity, and sexual orientation to sexually trans- mitted diseases and various types of sexual disorders.

If you have been troubled by problems with sexual arousal, inhib- ited orgasm, or premature orgasm, behavioral procedures can be helpful. Many of these problems can be treated successfully using behavioral and cognitive therapies. Before you seek professional therapy, you may want to try some self-help techniques that have developed from this treatment tradition. Two exceptionally well-writ- ten and practical books describe how these procedures can be used by people who want to enhance the pleasure that they experience in their sexual relationships. They are Becoming Orgasmic: A Sexual and Personal Growth Program for Women, by Julia Heiman and Jo- seph LoPiccolo, and The New Male Sexuality, by Bernie Zilbergeld.

If you are still experiencing problems after trying self-help proce- dures, you should seek treatment with a professional sex thera- pist. The person’s professional background is less important than her or his training for treatment of these specific problems. When you contact potential therapists, ask them whether their treatment methods are similar to those developed by Masters and Johnson. Information regarding counseling, therapy, medi- cal attention, and other sexuality resources for people with sexual problems is available from the Center for Disease Con- trol  and Prevention (their sexual health web page). Concise, readable descriptions of various forms of sexual dysfunction and treatments used to address them can be found at MedLine Plus, a service of the U.S. National Library of Medicine. These sites can help you increase your knowledge of sexuality, ways in which its expression can be inhibited, and procedures that can be used to improve sexual performance and experience.

Anyone who is interested in additional information regarding gender dysphoria will find help in a book called True Selves: Un- derstanding Transsexualism—for Families, Friends, Coworkers and Helping Professionals (Brown & Rounsley, 2003). The authors use extended interviews with patients and families to provide valuable insights regarding important issues encountered by people who struggle with these conditions.

346 CHAPTER 12 sexual dysfunctions, paraphilic disorders, and gender dysphoria

Sexual dysfunctions involve an inhibition of sexual desire or disruption of the physiological responses leading to orgasm.

Paraphilias are defined in terms of intense and persistent unusual sexual interests, in which sexual arousal is associated with atypical activities (such as exposing one’s genitals to strang- ers) or targets (inanimate objects or prepubescent children). A paraphilic disorder can be diagnosed when a paraphilia causes distress or social impairment for the person or threatens harm to another person.

Sexual dysfunctions are subdivided into several types. These include problems related to sexual desire, sexual arousal, and orgasm. Related difficulties include premature ejaculation, genito-pelvic pain, and interference with vaginal penetration.

Sexual behavior is dependent on a complex interaction among biological, psychological, and social factors. These factors include cognitive events related to the perception of sexual stimuli, social factors that influence sexual meanings or inten- tions, and physiological responses that cause vasocongestion of the genitals during sexual arousal.

Biological factors that contribute to sexual dysfunction include inadequate levels of sex hormones as well as a variety of medi- cal disorders. The effects of alcohol, illicit drugs, and some forms

of medication can also contribute to erectile dysfunction in men and to orgasmic disorder in both men and women.

Several psychological factors are involved in the etiology of sexual dysfunction. Prominent among these are performance anxiety and guilt. Communication deficits can also contrib- ute to sexual dysfunction. Previous experiences, including sexual abuse, play an important role in some cases of sexual dysfunction.

Psychological treatments for sexual dysfunction are quite suc- cessful. They focus primarily on negative attitudes toward sexu- ality, failure to engage in effective sexual behaviors, and deficits in communication skills.

Common characteristics of paraphilic disorders include lack of human intimacy and urges toward sexual behaviors that the person feels compelled to perform. The diversity and range of paraphilias are enormous. DSM-5 describes a few of the most prominent forms of paraphilic disorder, such as exhibitionis- tic, fetishism, frotteuristic, pedophilic, sexual masochism, sexual sadism, transvestic, and voyeuristic disorders.

Treatment outcome is generally less successful with paraphilic disorders than with sexual dysfunctions. Currently, the most promising approaches to the treatment of paraphilic disorders address a broad range of issues, including deficits in social skills and stress and anger management, as well as knowledge and attitudes regarding sexuality.

Gender dysphoria is a disturbance in the person’s sense of being either a man or a woman. People with this problem, which is also known as transsexualism, have developed a gender identity that is inconsistent with their physical anatomy. These disorders are extremely rare, and very little is known about their etiology. Treatment of gender dysphoria may involve sex-reassignment surgery.

Summary12

12.1 Should sexual problems be defined primarily in terms of difficulty reaching orgasm? It’s important to most people, but it’s not the only purpose of sexual activity. The person’s satisfaction with intimate relationships is also an important consideration . . . (see page 322).

12.2 What role to mental scripts play in sexual arousal? Scripts provide a perceptual structure, helping the person to rec- ognize a situation as being potentially sexual in nature . . . (see page 329).

12.3 What are the primary targets of psychological approaches to treating sexual dysfunctions? They focus on negative attitudes toward sexuality, failure to engage in effective sexual behaviors, and deficits in communication between partners . . . (see pages 330–331).

12.4 How have changing attitudes toward sexuality influenced the definition of paraphilias? A wider range of sexual behaviors is now considered to be normal when these activities occur in the context of an adult, mutually con- senting, reciprocal relationship . . . (see page 333).

critical thinking review

The Big Picture

sexual dysfunctions, paraphilic disorders, and gender dysphoria CHAPTER 12 347

key terms construct validity 325 delayed ejaculation 323 erectile disorder 323 exhibitionistic disorder 336 fetishistic disorder 334 frotteuristic disorder 337

gender identity 343 gender dysphoria 343 hypoactive sexual desire 324 hypothetical construct 325 inhibited sexual arousal 324 operational definition 325

orgasmic disorder 325 paraphilia 333 paraphilic disorder 333 pedophilic disorder 337 premature ejaculation 326 sensate focus 330

sexual dysfunction 321 sexual masochism

disorder 335 sexual sadism disorder 336 transvestic disorder 335 voyeuristic disorder 337

12.5 Should excessive sexual behavior be considered a disorder in its own right? Or is it a symptom of other mental disorders? One problem with the concept of hypersexual disorder is the heteroge- neous nature of poorly regulated sexual behavior, which can be associ- ated with many different forms of mental disorder . . . (see page 339).

12.6 Does deviant sexual arousal ever play a role in sexual assaults? Although rapes are often motivated by aggressive and violent impulses, some rapists are preoccupied by a sadistic blend of sexual and aggressive impulses that resembles qualities of other paraphilias . . . (see page 340).

12.7 Why are paraphilic disorders sometimes called “courtship disorders”? An evolutionary perspective suggests that some forms of paraphilia, such as voyeurism and exhibitionism, may represent maladaptive dis- tortions of normal mating behaviors . . . (see page 340).

12.8 What is the difference between gender identity and sex roles? The answer hinges on the distinction between a belief about “who you are” versus “what you do.” Gender identity is the fundamental sense of being either male or female. Sex roles are characteristics and behaviors that are considered to be either masculine or feminine . . . (see page 343).

13

schizophrenia spectrum and other psychotic disorders

schizophrenia spectrum and other psychotic disorders CHAPTER 13 349

13 The Big Picture learning objectives

13.1 Why do clinical scientists say that schizophrenia

is a “heterogeneous” disorder?

13.2 How should long-term outcome be

measured in schizophrenia?

13.3 Why are some personality disorders considered

to be schizophrenia spectrum disorders?

13.4 Why can’t we use brain imaging to

diagnose schizophrenia?

13.5 What characteristics would define a useful marker of vulnerability to schizophrenia?

13.6 What aspects of schizophrenia are addressed

most directly by psychosocial treatments?

Schizophrenia is a severe form of abnormal behavior that en- compasses what most of us have come to know as “madness.” People with schizophrenia exhibit many different kinds of psy- chotic symptoms, indicating that they have lost touch with re- ality. They may hear voices that aren’t there or make comments that are difficult, if not impossible, to understand. Their behavior may be guided by absurd ideas and beliefs. For example, a per- son might believe that spaceships from another planet are beam- ing thoughts into his brain and controlling his behavior. Some people with schizophrenia recover fairly quickly, whereas others deteriorate progressively after the initial onset of symptoms. It is a disorder with “many different faces” (Andreasen, 2001). Because of the diversity of symptoms and outcomes shown by these pa- tients, many clinicians believe that schizophrenia, or “the group of schizophrenias,” may actually include several forms of disorder that have different causes. Others contend that schizophrenia is a single pathological process and that variations from one patient to the next in symptoms and course of the disorder reflect differ- ences in the expression or severity of this process.

Overview Many of the disorders that we have discussed in this book strike us as being familiar, at least in form if not in severity. For ex- ample, depression and anxiety are experiences with which we can easily empathize. Short-lived versions of these emotions help to shape our responses to daily events. Some clinical scientists specu- late that mood and anxiety disorders may be viewed as evolved adaptations or mechanisms that can serve a useful purpose, but the symptoms of schizophrenia represent a different kind of prob- lem. It is much harder for us to understand when someone hears voices that aren’t there or speaks sentences that are meaningless. These symptoms seem to stem from a fundamental breakdown in basic cognitive functions that govern the way the person perceives and thinks about the social world (Burns, 2006).

The most common symptoms of schizophrenia include changes in the way a person thinks, feels, and relates to other peo- ple and the outside environment. No single symptom or specific set of symptoms is characteristic of all schizophrenic patients. All the individual symptoms of schizophrenia can also be associated with other psychological and medical conditions. Schizophrenia is officially defined by various combinations of psychotic symptoms in the absence of other forms of disturbance, such as mood disor- ders (especially manic episodes), substance use disorders, and neu- rocognitive disorders (delirium and dementia, see Chapter 14).

Schizophrenia is a devastating disorder for both the patients and their families (Bowie et al., 2010). It can disrupt many as- pects of the person’s life, well beyond the experience of psychotic symptoms. The impact of this disorder is felt in many different ways. For people who develop schizophrenia, it often has a dra- matic and lasting impact on their quality of life, both in terms of their own subjective satisfaction and their ability to complete an education, hold a job, and develop social relationships with other people. Approximately 10 percent of schizophrenic patients com- mit suicide (Heisel, 2008).

For family members of patients with schizophrenia, the con- sequences can also be cruel. They must come to grips with the fact that their son or daughter, or brother or sister, has developed a severe disorder that may change his or her life forever. One woman whose daughter, then in her mid-thirties, had exhibited symptoms of schizophrenia for 17 years, described her feelings in the following way: “Nothing in (our daughter’s) growing up years could have prepared us for the shock and devastation of seeing this normal, happy child become totally incapacitated by schizo- phrenia” (Smith, 1991, p. 691).

Schizophrenia also has an enormous impact on society (Be- han, Kennelly, & O’Callaghan, 2008). Among mental disorders, it is the second leading cause of disease burden (see Figure 1.2 on page 13). Most people who develop the disorder do not re- cover completely, and many become homeless because long-term institutional care is not available (see Chapter 18). Above and beyond the direct costs of providing treatment to patients and their families, substantial indirect costs are associated with loss of

350 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

that they contact a psychiatrist. After meeting with Ann briefly, the psychiatrist recommended that she be hospitalized for a short period of time.

After admission, Ann argued heatedly with the hospital staff, denying that she was mentally disturbed and insisting that she must be released so that she could protect her children from the conspiracy. She had no insight into the nature of her problems.

The onset of schizophrenia typically occurs during adolescence or early adulthood. The period of risk for the devel- opment of a first episode is considered to be between the ages of 15 and 35. The number of new cases drops off slowly after that, with very few people experiencing an initial episode after the age of 55 (Thompson, Pogue-Geile, & Grace, 2004).

The problems of most patients can be divided into three phases of variable and unpredictable duration: prodromal, active, and residual. Symptoms such as hallucinations, delusions, and disorganized speech are characteristic of the active phase of the disorder. The prodromal phase precedes the active phase and is marked by an obvious deterioration in role functioning as a stu- dent, employee, or homemaker. The person’s friends and relatives often view the beginning of the prodromal phase as a change in his or her personality. Prodromal signs and symptoms are simi- lar to those associated with schizotypal personality disorder (see Chapter 9). They include peculiar behaviors (such as talking to one’s self in public), unusual perceptual experiences, outbursts of anger, increased tension, and restlessness. Social withdrawal,

productivity and unemployment. In the United States the finan- cial costs associated with schizophrenia were approximately $63 billion in 2002 (Wu, et al., 2005).

In the following case studies we describe the experiences of two people who exhibited symptoms of schizophrenia. The symptoms of schizophrenia take many forms. Our first case illus- trates one relatively common pattern in which the person is pre- occupied by paranoid delusions and becomes socially withdrawn.

A New Mother’s Paranoid Delusions Ann was 21 years old the first time that she was admitted to a psychiatric hospital. She had completed business college and had worked as a receptionist until she became pregnant with her son, who was born six months prior to her admission. She and her hus- band lived in a small apartment with his five-year-old daughter from a previous marriage. This was her first psychotic episode.

The first signs of Ann’s disturbance appeared during her pregnancy, when she accused her husband of having an affair with her sister. The accusation was based on a conversation that Ann had overheard on a bus. Two women (who were neighbors in Ann’s apartment building) had been discussing an affair that some woman’s husband was having. Ann believed that this might have been their way of telling her about her husband’s infidelity. Although her husband and her sister denied any romantic interest in each other, Ann clung to her suspicions and began to monitor her husband’s activities closely. She also avoided talking with her neighbors and friends.

Before this period of time, Ann had been an outgoing and energetic person. Now she seemed listless and apathetic and would often spend days without leaving their apartment. Her hus- band at first attributed this change in her behavior to the preg- nancy, believing that she would “snap out of it” after the baby was born. Unfortunately, Ann became even more socially isolated following the birth of her son. She seldom left her bedroom and would spend hours alone, mumbling softly to herself.

Ann’s behavior deteriorated markedly two weeks prior to her hospital admission, when she noticed that some photographs of herself and her baby were missing. She told her husband that they had been stolen and were being used to cast a voodoo spell on her. Ann became increasingly preoccupied with this belief in subsequent days. She called her mother repeatedly, insisting that something would have to be done to recover the missing photo- graphs. Her friends and family tried to reassure Ann that the pho- tographs had probably been misplaced or accidentally discarded, but she was totally unwilling to consider alternative explanations.

Ann finally announced to everyone who would listen that someone was trying to kill her and the children. Believing that all the food in the house had been poisoned, she refused to eat and would not feed the children.

She became increasingly suspicious, hostile, and combative. Her husband and parents found it impossible to reason with her. She was no longer able to care for herself or the children. The fam- ily sought advice from their family physician, who recommended

Painting by a young schizophrenic patient, illustrating his hallucinations. He saw monsters, like the one painted here, crawling on the floor. He also believed that the chairs next to his bed had turned into devils. Patient’s description of the picture: “I was very sick at the time I painted this picture. The head represents my fragmented personality and a feeling of being helpless, hopeless, and off balance and of being in a cocoon of unreality. The bright colored rain and outlines represent the level of intensity of my- self. The bright colors provided insulation and protected me. The colors felt like microwaves passing through my control center.”

schizophrenia spectrum and other psychotic disorders CHAPTER 13 351

meant. Edward responded by asking his own question, “If you had a star in the middle of your head, would you swallow marbles?”

Edward’s expressive gestures were severely restricted, and he sat in a relatively motionless position. Although he said that he was frightened by the recent events that he reported to his mother, his face did not betray any signs of emotion. He mum- bled slowly in a monotonous tone of voice that was difficult to understand. He said that he could hear God’s voice telling him that his father was “the master of the universe” and he claimed that he had “seen the shadow of the master.”

Other voices seemed to argue with one another about Ed- ward’s special calling and whether he was worthy of this divine power. The voices told him to prepare for God’s return to earth. At times Edward said that he was a Nazi soldier and that he was born in Germany in 1886. He also spoke incoherently about corpses frozen in Greenland and maintained that he was “only half a person.”

Symptoms In this section, we describe in greater detail various types of symp- toms that are commonly observed among schizophrenic patients and that are currently emphasized by official diagnostic systems, such as DSM-5. All of these symptoms can fluctuate in severity over time. Some patients exhibit persistent psychotic symptoms. Others experience symptoms during acute episodes and are better adjusted between episodes.

The symptoms of schizophrenia can be divided into three dimensions: positive symptoms, negative symptoms, and disor- ganization (Lenzenweger, 1999). Positive symptoms, also called psychotic symptoms, include hallucinations and delusions. In con- trast, negative symptoms include characteristics such as lack of initiative, social withdrawal, and deficits in emotional responding. Some additional symptoms of schizophrenia, such as incoherent

indecisiveness, and lack of willpower are often seen during the prodromal phase (Woods, et al., 2009).

The residual phase follows the active phase of the disorder and is defined by signs and symptoms that are similar in many respects to those seen during the prodromal phase. At this point, the most dramatic symptoms of psychosis have improved, but the person continues to be impaired in various ways. Negative symp- toms, such as impoverished expression of emotions, may remain pronounced during the residual phase (McGlashan, 1998).

After the onset of schizophrenia, many people do not return to expected levels of social and occupational adjustment. Some prefer social isolation and avoid contact with other people. The man in our second case illustrates this pattern. He is also an example of the disorganized type of schizophrenia. Patients who fit criteria for this category say things that are difficult to understand, behave in a disorganized way, and fail to express expected emotions.

Edward’s Hallucinations and Disorganized Speech Edward was 39 years old and had lived at home with his par- ents since dropping out of school after the tenth grade. Edward worked on and off as a helper in his father’s roofing business prior to his first psychotic episode at the age of 26. After that time, he was socially isolated and unable to hold any kind of job. He was hospitalized in psychiatric facilities 10 times in the next 14 years. When he was not in the hospital, most of his time at home was spent watching television or sitting alone in his room.

The tenth episode of psychosis became evident when Ed- ward told his mother that he had seen people arguing violently on the sidewalk in front of their house. He believed that this incident was the beginning of World War II. His mother tried to persuade him that he had witnessed an ordinary, though perhaps heated, disagreement between two neighbors, but Edward could not be convinced. He continued to mumble about the fight and became increasingly agitated over the next few days. When he wasn’t pacing back and forth from his bedroom to the living room, he could usually be found staring out the front window. Several days after witnessing the argument, he took curtains from several windows in the house and burned them in the street at 2 A.M. A neighbor happened to see what Edward was doing and called the police. When they arrived, they found Edward wandering in a snow-covered vacant lot, talking incoherently to himself. Recognizing that Edward was psychotic, the police took him to the psychiatric hospital.

Although his appearance was somewhat disheveled, Edward was alert and cooperative. He knew the current date and recog- nized that he was in a psychiatric hospital. Some of his speech was incoherent, and his answers to questions posed by the hos- pital staff were frequently irrelevant. For example, the following exchange occurred during a structured diagnostic interview. The psychologist asked Edward whether he had any special powers or abilities that other people do not have. He responded by saying that he didn’t know because he didn’t date women. Puzzled by this tangential response, the psychologist asked him to explain what he

Many of the symptoms of schizophrenia, including hallucinations and de- lusions, can be extremely distressing.

352 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

or disorganized speech, do not fit easily into either the positive or negative types. Verbal communication problems and bizarre be- havior represent this third dimension, which is sometimes called disorganization. These symptom dimensions overlap and combine in various ways within individual patients. In the following pages, we will describe the most obvious features of these symptoms. It should also be noted, however, that attenuated versions of these symptoms occur relatively frequently in people who are not psy- chotic (Dominguez, et al., 2010). Like other features of psycho- pathology, these symptoms are not all-or-nothing phenomena; they are best viewed as falling along a continuous dimension of severity.

Positive Symptoms The term positive symptoms of schizophrenia does not imply that these symptoms are beneficial or adaptive. Rather, it suggests that they are characterized by the presence of an aberrant response (such as hearing a voice that is not really there). Negative symp- toms, on the other hand, are characterized by the absence of a particular response (such as emotion, speech, or willpower).

HALLUCINATIONS Our senses provide us with basic informa- tion that is vital to our notions of who we are, what we are doing, and what others think of us. Many people with schizophrenia experience perplexing and often frightening changes in percep- tion. The most obvious perceptual symptoms are hallucinations, or sensory experiences that are not caused by actual external stimuli. Although hallucinations can occur in any of the senses, those experienced by schizophrenic patients are most often audi- tory. Many patients hear voices that comment on their behavior or give them instructions. Others hear voices that seem to argue with one another. Edward heard the voice of God talking to him. Like Edward, most patients find such voices to be frightening. In some cases, however, hallucinations can be comforting or pleas- ing to the patient.

Hallucinations should be distinguished from the transient mistaken perceptions that most people experience from time to time (Brébion, et al., 2008). Have you ever turned around after thinking you heard someone call your name, to find that no one was there? You probably dismissed the experience as “just your imagination.” Hallucinations, in contrast, strike the person as be- ing real, in spite of the fact that they have no basis in reality. They can vary in terms of both duration and severity. Patients who ex- perience more severe auditory hallucinations hear the voice (or voices) speaking to them throughout the day and for many days at a time.

DELUSIONAL BELIEFS Many schizophrenic patients express de- lusions, or idiosyncratic beliefs that are rigidly held in spite of their preposterous nature (Maher, 2001). Delusions have some- times been defined as false beliefs based on incorrect inferences about reality. This definition has a number of problems, including the difficulty of establishing the ultimate truth of many situations.

Ann’s accusation that her husband was having an affair, for ex- ample, could easily become a choice between her word and his. This suspicion would not, on its own, be considered a delusion. The judgment that her beliefs were delusional depended to a large extent on their expansion to more absurd concerns about stolen photographs, voodoo spells, and alleged plots to kill her children.

Several additional characteristics are important in identifying delusions (Lincoln et al., 2007). In the most severe cases, delu- sional patients express and defend their beliefs with utmost con- viction, even when presented with contradictory evidence. For example, Ann’s belief that the stolen photographs were being used to cast a spell on her was totally fixed and resistant to contradic- tion or reconsideration. Preoccupation is another defining char- acteristic of delusional beliefs. During periods of acute psychosis, many patients like Ann find it difficult, if not impossible, to avoid thinking or talking about these beliefs. Finally, delusional patients may be unable to consider the perspective that other people hold with regard to their beliefs. Ann, for example, was unable to ap- preciate the fact that other people considered her paranoid beliefs to be ridiculous. Taken together, these characteristics describe ways of identifying the severity of delusional beliefs.

Although delusional beliefs can take many forms, they are typi- cally personal. They are not shared by other members of the per- son’s family or cultural group. Common delusions include the belief that thoughts are being inserted into the patient’s head, that other people are reading the patient’s thoughts, or that the patient is be- ing controlled by mysterious, external forces (Gutierrez-Lobos et al., 2001). Many delusions focus on grandiose or paranoid content. For example, Edward expressed the grandiose belief that his father was the Master of the universe. Ann clung persistently to the paranoid belief that someone was trying to kill her and her children.

In actual clinical practice, delusions are complex and diffi- cult to define (Lesser & O’Donohue, 1999; Oltmanns, 1988). Their content is sometimes bizarre and confusing, as in the case of Edward’s insistence that he had witnessed the beginning of World War II. Delusions are often fragmented, especially among

MyPsychLab VIDEO CASE

Schizophrenia

LARRY

“My voices had gotten the most of me. . . .”

Watch the Video Larry: Schizophrenia on MyPsychLab

Pay attention to the nonverbal aspects of Larry’s behavior during the interview (lack of

expression in face and voice). Notice that, in spite of his symptoms, he does express satisfaction with his life.

schizophrenia spectrum and other psychotic disorders CHAPTER 13 353

severely disturbed patients. In other words, delusions are not al- ways coherent belief systems that are consistently expressed by the patient. At various times, for example, Edward talked about be- ing a Nazi soldier and half a person. Connections among these fragmented ideas are difficult to understand.

The subjective experiences of people who struggle with schizophrenia are an important source of knowledge about this disorder, particularly delusional beliefs. Some of the most fun- damental elements of psychosis involve private events that can- not be observed directly by others. Fortunately, many articulate patients have provided compelling accounts of their own internal struggles. The box below is a first person account by a patient who is being treated for schizophrenia. She describes experiences that are part of an elaborate delusional belief system.

Negative Symptoms Negative symptoms of schizophrenia are defined in terms of responses or functions that appear to be missing from the per- son’s behavior. In that sense, they may initially be more subtle or

difficult to recognize than the positive symptoms of this disorder. Negative symptoms tend to be more stable over time than posi- tive symptoms, which fluctuate in severity as the person moves in and out of active phases of psychosis (Buchanan, 2007; Stahl & Buckley, 2007).

AFFECTIVE AND EMOTIONAL DISTURBANCES One of the most common symptoms of schizophrenia involves a flatten- ing or restriction of the person’s nonverbal display of emotional responses. This symptom, called diminished emotional ex- pression, or blunted affect, was clearly present in Edward’s case. Patients with this symptom fail to exhibit signs of emotion or feeling. They are neither happy nor sad, and they appear to be completely indifferent to their surroundings. Their faces are apa- thetic and expressionless. Their voices lack the typical fluctuations in volume and pitch that other people use to signal changes in their mood. Events in their environment hold little consequence for them. They may demonstrate a complete lack of concern for themselves and for others (Blanchard, Cohen, & Carreño, 2007).

First-Person Account of Delusional Beliefs

At the beginning of my last year at (the university), “feel-ings” began to descend on me. I felt distinctly different from my usual self. I would sit for hours on end staring at nothing, and I became fascinated with drawing weird, discon- nected monsters. I carefully hid my drawings, because I was certain I was being watched. Eventually, I became aware of a magical force outside myself that was compelling me in certain directions. The force gained power as time went on, and soon it made me take long walks at 2 or 3 o’clock in the morning down dark alleys in my high-crime neighborhood. I had no power to disobey the force. During my walks I felt as though I was in a different, magical, four-dimensional universe. I understood that the force wanted me to take those walks so that I might be killed.

I do not clearly understand the relationship between the force and the Alien Beings (alas, such a name!), but my universe soon became populated with them. The Alien Beings were from outer space, and of all the people in the world, only I was aware of them. The Alien Beings soon took over my body and removed me from it. They took me to a faraway place of beaches and sunlight and placed an Alien in my body to act like me. At this point, I had the distinct impression that I did not really exist, because I could not make contact with my kidnapped self. I also saw that the Aliens were starting to take over other people as well, removing them from their bodies and putting Aliens in their place. Of course, the other people were unaware of what

was happening; I was the only person in the world who had the power to know it. At this point, I determined that the Aliens were involved in a huge conspiracy against the world.

The Alien Beings were gaining strength and had given me a complex set of rules. The rules were very specific and governed every aspect of my behavior. One of the rules was that I could not tell anyone else about the Aliens or the rules, or else the Aliens would kill me. Another of the rules was that I had to be- come utterly, completely mad. So now I was living in a world of great fear.

I had a number of other symptoms as well. I felt as though I had been pushed deep within myself, and I had little or no reaction to events or emotions around me. Almost daily the world be- came unreal to me. Everything outside of me seemed to fade into the distance; everything was miles away from me. I came to feel that I had the power to influence the behavior of animals; that I could, for instance, make dogs bark simply by hooking up rays of thought from my mind to theirs. Conversely, I felt that certain people had the capacity to read my mind. I became very frightened of those people and tried my best to avoid them. Whenever I saw a group of two or three people, I was sure they were talking about me. Paranoia is a very painful emotion! But when I saw crowds of people (as in a shopping mall), I felt an acute longing to wander among them, singing hymns and nurs- ery rhymes (Payne, 1992, pp. 726–727).

354 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

Another type of emotional deficit is called anhedonia, which refers to the inability to experience pleasure. Whereas diminished emotional expression refers to the lack of outward expression, an- hedonia is a lack of positive subjective feelings. People who expe- rience anhedonia typically lose interest in recreational activities and social relationships, which they do not find enjoyable. They may also be unable to experience pleasure from physical sensa- tions, such as taste and touch.

Longitudinal studies indicate that anhedonia associated with both social and physical experiences is an enduring feature of the disorder for many people with schizophrenia (Herbener & Har- row, 2002). For some people, it may also be an early marker, sig- naling the onset of the prodromal phase of the disorder (Kwapil, 1998). Like other symptoms of schizophrenia, anhedonia is not unique to this disorder; it is also found among people who are severely depressed.

AVOLITION AND ALOGIA One of the most important and seriously debilitating aspects of schizophrenia is a malfunction of interpersonal relationships (Meehl, 1993). Many people with schizophrenia become socially withdrawn. In many cases, social isolation develops before the onset of symptoms, such as halluci- nations and delusions. It can be one of the earliest signs that some- thing is wrong. This was certainly true in Ann’s case. She became socially isolated from her family and friends many weeks before she started to talk openly about the stolen pictures and the plot to kill her children. Social withdrawal appears to be both a symptom of the disorder and a strategy that is actively employed by some patients to deal with their other symptoms. They may, for exam- ple, attempt to minimize interactions with other people in order to reduce levels of stimulation that can exacerbate perceptual and cognitive disorganization (Walker, Davis, & Baum, 1993).

The withdrawal seen among many schizophrenic patients is accompanied by indecisiveness, ambivalence, and a loss of will- power. This symptom is known as avolition (lack of volition or will). A person who suffers from avolition becomes apathetic and ceases to work toward personal goals or to function indepen- dently. He or she might sit listlessly in a chair all day, not washing or combing his or her hair for weeks.

Another negative symptom involves a form of speech distur- bance called alogia, which refers to impoverished thinking. Liter- ally translated, it means “speechlessness.” In one form of alogia, known as poverty of speech, patients show remarkable reductions in the amount of speech. They simply don’t have anything to say. In another form, referred to as thought blocking, the patient’s train of speech is interrupted before a thought or idea has been completed.

Disorganization Some symptoms of schizophrenia do not fit easily into either the positive or negative type. Thinking disturbances and bizarre be- havior represent a third symptom dimension, which is sometimes called disorganization (Rietkerk, et al., 2008).

THINKING DISTURBANCES One important set of schizophrenic symptoms, known as disorganized speech, involves the tendency of some patients to say things that don’t make sense. Signs of dis- organized speech include making irrelevant responses to ques- tions, expressing disconnected ideas, and using words in peculiar ways (Berenbaum & Barch, 1995). This symptom is also called thought disorder, because clinicians have assumed that the failure to communicate successfully reflects a disturbance in the thought patterns that govern verbal discourse. The woman described in the following case exhibited signs of disorganized speech.

Marsha’s Disorganized Speech and Catatonic Behavior Marsha was a 32-year-old graduate student in political science. She had never been treated for psychological problems.

Marsha called Dr. Higgins, a clinical psychologist who taught at the university, to ask if she could speak with him about her twin sister’s experience with schizophrenia. When she arrived at his office, she was neatly dressed and had a Bible tucked tightly under her arm. The next three hours were filled with a rambling discussion of Marsha’s experiences during the past 10 years. She talked about her education, her experience as a high school teacher before returning to graduate school, her relationships with her parents, and most of all her concern for her identical twin sister, Alice, who had spent six of the last 10 years in psy- chiatric hospitals.

Marsha’s emotional expression vacillated dramatically throughout the course of this conversation, which was punctu- ated by silly giggles and heavy sighs. Her voice would be loud and emphatic one moment as she talked about her stimulating ideas and special talents. At other moments, she would whis- per in a barely audible voice or sob quietly as she described the desperation, fear, and frustration that she had experienced watching the progression of her sister’s disorder. She said that she had been feeling very uptight in recent months, afraid that she might be “going crazy” like her sister. She had been scared to death to go home because her parents might sense that something was wrong with her. Her behavior was frequently inconsistent with the content of her speech. As she described her intense fears, for example, Marsha occasionally giggled uncontrollably.

Dr. Higgins also found Marsha’s train of thought difficult to follow. Her speech rambled illogically from one topic to the next, and her answers to his questions were frequently tangen- tial. For example, when Dr. Higgins asked what she meant by her repeated use of the phrase “the ideal can become real,” Marsha replied, “Well, after serving the Word of Christ in California for three years, making a public spectacle of myself, someone ap- parently called my parents and said I had a problem. I said I can’t take this anymore and went home. I perceived that Mom was just unbelievably nice to me. I began to think that my face was chang- ing. Something about my forehead resembled the pain of Christ. I served Christ, but my power was not lasting.”

schizophrenia spectrum and other psychotic disorders CHAPTER 13 355

At the end of this three-hour interview, Dr. Higgins was convinced that Marsha should be referred to the mental health center for outpatient treatment. He explained his concerns to Marsha, but she refused to follow his advice, insisting that she did not want to receive the medication with which her sister had been treated. She agreed to return to Dr. Higgins’s office in three days for another interview, but she did not keep that appointment.

Two weeks later, Marsha called Dr. Higgins to ask if he would talk with her immediately. It was very difficult to understand what she was saying, but she seemed to be repeating in a shrill voice “I’m losing my mind.” The door to his office was closed when she arrived, but he could hear her shuffling awkwardly down the hallway, breathing heavily. He opened his door and found Mar- sha standing in a rigid posture, arms stiffly at her sides. Her eyes were opened wide, and she was staring vacantly at the name- plate on his door. In contrast to her prim and neat appearance at their first meeting, Marsha’s hair and clothes were now in disar- ray. She walked stiffly into the office without bending her knees and sat, with some difficulty, in the chair next to Dr. Higgins’s desk. Her facial expression was rigidly fixed. Although her eyes were open and she appeared to hear his voice, Marsha did not respond to any of Dr. Higgins’s questions. Recognizing that Mar- sha was experiencing an acute psychotic episode, Dr. Higgins and one of the secretaries took her to the emergency room at the local hospital.

Marsha’s speech provides one typical example of disorganized speech. She was not entirely incoherent, but parts of her speech were difficult to follow. Connections between sentences were sometimes arbitrary, and her answers to the interviewer’s ques- tions were occasionally irrelevant.

Several types of verbal communication disruption contrib- ute to clinical judgments about disorganized speech (Docherty, DeRosa, & Andreasen, 1996; Kerns & Berenbaum, 2002). Com- mon features of disorganized speech in schizophrenia include shifting topics too abruptly, called loose associations or derailment; replying to a question with an irrelevant response, called tangen- tiality; or persistently repeating the same word or phrase over and over again, called perseveration. We all say things from time to time that fit these descriptions. It is not the occasional presence of a single feature but, rather, the accumulation of a large number of such features that defines the presence of disorganized speech.

ABNORMAL MOTOR BEHAVIOR Schizophrenic patients may exhibit various forms of unusual motor behavior, such as the ri- gidity displayed by Marsha when she appeared for her second in- terview with Dr. Higgins. Catatonic behavior refers to an obvious reduction in reactivity to external stimuli. It most often refers to immobility and marked muscular rigidity, but it can also refer to excitement and overactivity. For example, some patients en- gage in apparently purposeless pacing or repetitious movements,

such as rubbing their hands together in a special pattern for hours at a time. Many catatonic patients exhibit reduced or awkward spontaneous movements. In more extreme forms, patients may assume unusual postures or remain in rigid standing or sitting positions for long periods of time. For example, some patients will lie flat on their backs in a stiff position with their heads raised slightly off the floor as though they were resting on a pillow. Catatonic patients typically resist attempts to alter their position, even though maintaining their awkward postures would normally be extremely uncomfortable or painful.

Catatonic posturing is often associated with a stuporous state, or generally reduced responsiveness. The person seems to be un- aware of his or her surroundings. For example, during her acute psychotic episode, Marsha refused to answer questions or to make eye contact with others. Unlike people with other stuporous con- ditions, however, catatonic patients seem to maintain a clear state of consciousness, and it is likely that Marsha could hear and un- derstand everything that Dr. Higgins said to her. Many patients report after the end of a catatonic episode that they were perfectly aware of events that were taking place around them, in spite of their failure to respond appropriately.

Another kind of bizarre behavior involves affective responses that are obviously inconsistent with the person’s situation. This symptom is particularly difficult to describe in words. The most remarkable features of inappropriate affect are incongruity and lack of adaptability in emotional expression. For example, when Marsha described the private terror that she felt in the presence of her family, she giggled in a silly fashion. The content of Marsha’s speech was inconsistent with her facial expression, her gestures, and her voice quality.

Diagnosis The broad array of symptoms outlined in the previous section has all been described as being part of schizophrenic disorders. The specific organization of symptoms has been a matter of some controversy for many years, and schizophrenic disorders have been defined in many different ways. One popular misconcep- tion should be mentioned at the outset. The term schizophrenia was coined in 1911 by Eugen Bleuler, a Swiss psychiatrist. This term referred to the splitting of mental associations, which Bleuler believed to be the fundamental disturbance in schizophrenia. One unfortunate consequence of this choice of terms has been that laypeople frequently confuse schizophrenia with dissociative identity disorder (also known as multiple personality). The latter is a severe form of dissociative disorder (see Chapter 7), and it has little in common with schizophrenia.

DSM-5 Several specific criteria for schizophrenia are listed in DSM-5 (see “DSM-5: Schizophrenia”). The first requirement (Criterion A) is that the patient must exhibit two (or more) active symptoms for at least one month. Negative symptoms, such as diminished

356 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

emotional expression and avolition, also play a relatively promi- nent role in the DSM-5 definition of schizophrenia.

The DSM-5 definition takes into account the person’s level of functioning as well as the duration of the disorder (Criteria B and C). It requires evidence of a decline in the person’s social or occupational functioning as well as the presence of disturbed behavior over a continuous period of at least six months. Active phase symptoms do not need to be present for this entire period. The total duration of disturbance is determined by adding to- gether continuous time during which the person has exhibited prodromal, active, and residual symptoms of schizophrenia. If the person displays psychotic symptoms for at least one month but less than six months, the diagnosis would be schizophreni- form disorder. The diagnosis would be changed to schizophrenic disorder if the person’s problems persisted beyond the six-month limit.

The final consideration in arriving at a diagnosis of schizo- phrenia involves the exclusion of related conditions, especially mood disorders. According to DSM-5, active phase symptoms of schizophrenia must appear in the absence of a major depressive or manic episode. If symptoms of depression or mania are present, their duration must be brief relative to the duration of the active and residual symptoms of schizophrenia.

Subtypes Schizophrenia is a heterogeneous disorder with many different clinical manifestations and levels of severity. The title of Bleul- er’s classic text referred to “the group of schizophrenias” in an effort to draw attention to the varied presentations of the dis- order. It is not clear, however, how best to think about the dif- ferent forms of schizophrenia. Many clinicians and investigators believe that schizophrenia is a general term for a group of disor- ders, each of which may be caused by a completely different set of factors. Other clinicians believe that the numerous symptoms of schizophrenia are most likely varying manifestations of the same underlying condition (Gottesman, 1991). Given the cur- rent state of evidence, it is not possible to choose between these conceptual options. Nevertheless, most investigators agree that we should at least consider the possibility that there are distinct forms.

Previous versions of the diagnostic manual, tracing back to DSM-I, have recognized several official subtypes of schizophre- nia. These included the paranoid, disorganized, catatonic, and undifferentiated subtypes, with the latter being used to identify patients who meet criteria for several subtypes of schizophrenia at the same time. The subtypes were used to describe the most prominent symptoms exhibited by the patient during the most

criteria for Schizophrenia

A. Two (or more) of the following, each present for a sig- nificant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or

incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional ex-

pression or avolition).

B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, aca- demic, or occupational functioning).

C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms.

During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unu- sual perceptual experiences).

D. Schizoaffective disorder and depressive or bipolar disor- der with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occured concurrently with the active-phase symptoms, or 2) if mood episodes have occured during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medica- tion) or another medical condition.

F. If there is a history of autism spectrum disorder or a com- munication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delu- sions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

DSM-5

schizophrenia spectrum and other psychotic disorders CHAPTER 13 357

recent episode. DSM-5 has eliminated these symptom-based sub- types because the research evidence that accumulated over a pe- riod of many years indicated clearly that they were not valid (see Critical Thinking Matters).

Related Psychotic Disorders The schizophrenia spectrum disorders that are listed in DSM-5 include several additional disorders that are characterized by prominent psychotic symptoms. The manual also notes that schizotypal personality disorder (see Chapter 9) should be recog- nized as part of the schizophrenia spectrum.

People with delusional disorder do not meet the full symp- tomatic criteria for schizophrenia, but they are preoccupied for at least one month with delusions that are not bizarre. These are beliefs about situations that could occur in real life, such as be- ing followed or poisoned. Ann’s delusion, for example, might have fit this description. She believed that someone was trying to kill her and her children and that someone was trying to cast a voodoo spell on them. Ann would not be assigned a diagnosis of delusional disorder, however, because she also displayed negative

symptoms, such as avolition. The presence of hallucinations, dis- organized speech, catatonic behavior, or negative symptoms rules out a diagnosis of delusional disorder. The definition of delu- sional disorder also holds that the person’s behavior is not bizarre and that social and occupational functioning are not impaired except for those areas that are directly affected by the delusional belief.

Brief psychotic disorder is a category that includes those people who exhibit psychotic symptoms—delusions, hallucina- tions, disorganized speech, or grossly disorganized or catatonic behavior—for at least one day but no more than one month. An episode of this sort is typically accompanied by confusion and emotional turmoil, often (but not necessarily) following a mark- edly stressful event. After the symptoms are resolved, the person returns to the same level of functioning that had been achieved prior to the psychotic episode. The long-term outcome is good for most patients who experience a brief episode of psychosis (Susser, et al., 1998). This diagnosis is not assigned if the symp- toms are better explained by a mood disorder, schizophrenia, or substance abuse.

CRITICAL THINKING matters

Why Were the Symptom-Based Subtypes of Schizophrenia Dropped from DSM-5?

The validity of the traditional subtypes was debated for many years. The evidence on which they are based was weak. Clinicians who favored continued use of subtype diagnoses claimed that these categories are moderately stable over time (Fenton, 2000). There is also some evidence indicating that patients who fit descriptions of the catatonic and paranoid subtypes have a somewhat better prognosis, whereas those in the disorganized subtype may have—on average—a worse prognosis (McGlashan & Fenton, 1991). If we think critically, this was not strong support for the inclusion of these subtypes in the official diagnostic manual.

Critics pointed to a number of serious problems. Traditional subtypes do not strongly predict either the course of the disor- der or response to treatment. The subtypes also have relatively poor diagnostic reliability and are frequently unstable over time. Patients who fit a traditional subcategory during one psychotic episode frequently qualified for a different subtype diagnosis during a subsequent episode. Based on this evidence, it became reasonable to ask: “How does it help the clinician or the patient to assign a subtype diagnosis such as disorganized type or undif- ferentiated type?”

Perhaps the most important consideration with regard to the validity of subtypes involves the genetic evidence. Studies of extended families suggest that the subtypes are not etiologically distinct syndromes (Cardno et al., 1998; Linscott et al., 2010). If

several members of a family—or two members of a monozygotic twin pair—have developed symptoms of schizophrenia, they will not necessarily exhibit symptoms of the same subtype. That fact argues strongly against the notion that the subtypes are qualita- tively different disorders.

This is perhaps the greatest irony in research on schizophre- nia. For more than 100 years, clinicians and investigators have agreed that the disorder is extremely heterogenous. The diag- nostic category that we now recognize as schizophrenia may well be composed of many different kinds of mental disorders. This common opinion stands in contrast to the harsh fact that no one has been able to identify truly meaningful subtypes. At best, the diagnostic subtypes for schizophrenia were placehold- ers, serving primarily to remind us that the disorder is hetero- geneous in nature. For all of the reasons mentioned above, the DSM-5 workgroup for schizophrenia decided that it was finally time to drop the symptom-based subtypes from the diagnostic manual. We desperately need more knowledge in this area. We need better research that will help us find truly meaningful subtypes based on sophisticated measurement procedures that may involve genetic factors, cognitive performance, treatment response, or some other facet of the disorder that has not yet been studied. One thing that does seem to be clear is that it has not been particularly useful to focus on symptoms as the basis for reducing the heterogeneity of the complex disorder.

358 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

The diagnostic criteria for schizophreniform disorder are ex- actly the same as those for schizophrenia (in Criterion A). The difference between them is based on the duration of symptoms. Total duration for schizophreniform disorder is more than one month but less than six months. If the person does not recover af- ter six months, the diagnosis would be changed to schizophrenia. In terms of duration, schizophreniform disorder falls between brief psychotic disorder (which lasts at least one day but less than one month) and schizophrenia.

Schizoaffective disorder is an ambiguous and somewhat controversial category (Averill, et al., 2004; Lake & Hurwitz, 2007). It describes the symptoms of patients who fall on the boundary between schizophrenia and mood disorder with psy- chotic features. This diagnosis applies only to the description of a particular episode of disturbance; it does not describe the overall lifetime course of the person’s disorder. Schizoaffective disorder is defined by an episode in which the symptoms of schizophre- nia partially overlap with a major depressive episode or a manic episode. The key to making this diagnosis is the presence of delu- sions or hallucinations for at least two weeks in the absence of prominent mood symptoms. If the delusions and hallucinations

are present only during a depressive episode, for example, the diagnosis would be major depressive episode with psychotic features.

Course and Outcome Schizophrenia is a severe, progressive disorder that most often begins in adolescence and typically has a poor outcome. In fact, classic descriptions of the disorder considered the deteriorating course to be one of the principal defining features. Current ev- idence suggests that this view may be unnecessarily pessimistic (Hafner, et al., 2003; Perkins, Miller-Anderson, & Lieberman, 2006). Many patients experience a more favorable outcome in the sense that their symptoms are improved. For example, Manfred Bleuler (1978) studied a sample of 208 schizophrenic patients who had been admitted to his hospital in Switzerland during 1942 and 1943. After a follow-up period of 23 years, 53 percent of the patients were either recovered or significantly im- proved. More recent evidence indicates that, while some patients do have a positive outcome, relatively few are able to achieve suc- cessful aging (Lang, et al., 2013).

Follow-up studies of schizophrenic patients have found that the description of outcome is a complicated process (Harvey et al., 2009). Many factors must be taken into consideration other than whether the person is still in the hospital. Is the person still ex- hibiting symptoms of the disorder? Does he or she have any other problems, such as depression or anxiety? Is the person employed? Does she have any friends? How does he get along with other people? The evidence indicates that different dimensions of out- come, such as social adjustment, occupational functioning, and symptom severity are only loosely correlated. As in most situa- tions where psychologists attempt to predict future behavior, the outcome data regarding schizophrenia suggest that the best pre- dictor of future social adjustment is previous social adjustment. Similarly, the best predictor of symptom severity at follow-up is severity of psychotic symptoms at initial assessment (Bromet, et al., 2005).

Elyn Saks, a professor at the University of Southern California and recipient of a MacArthur Foundation “genius award,” has written eloquently about her ex- perience with schizophrenia in her autobiography, The Center Cannot Hold: My Journey Through Madness. In her TED talk, she argues persuasively that “there’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life.”

MyPsychLab VIDEO CASE

Schizoaffective Disorder

JOSH

“When I was first in the hospital, I thought I was in the middle of a massacre . . .”

Watch the Video Josh: Schizoaffective Disorder on MyPsychLab

In addition to describing bizarre delusional beliefs, Josh has also experienced several

symptoms of bipolar mood disorder, such as racing thoughts and grandiosity.

schizophrenia spectrum and other psychotic disorders CHAPTER 13 359

Frequency One of the most informative ways of examining the frequency of schizophrenia is to consider the lifetime prevalence—that is, the proportion of a specific population that will be af- fected by the disorder at some time during their lives. Most studies in Europe and the United States have reported lifetime prevalence figures of approximately 1.0 percent if they in- clude people who meet diagnostic criteria for schizophrenia as well as related psychotic disorders (Kessler et al., 2005; Saha, Chant, & McGrath, 2008). In other words, approximately one out of every 100 people will experience or display symptoms of schizophrenia at some time during their lives. Of course, prevalence rates depend on the diagnostic criteria that are used to define schizophrenia in any particular study, as well as the methods that are used to identify cases in the general popu- lation. Investigators who have employed more narrow or re- strictive criteria for the disorder report lower prevalence rates (Messias, Chen, & Eaton, 2007).

Gender Differences Although experts believed for many years that men and women are equally likely to develop schizophrenia, this conclusion has been challenged by several recent studies. Current evidence suggests that men are 30 to 40 percent more likely to develop schizophrenia than women (Seeman, 2008).

There are some interesting and widely recognized differ- ences between male and female patients with regard to patterns of onset, symptoms, and course of the disorder. For example, the

average age at which schizophrenic males begin to exhibit overt symptoms is younger by about four or five years than the average age at which schizophrenic women first experience problems. A summary of reported gender differences in schizophrenia is pre- sented in Table 13.1 on page 360. Male patients are more likely than female patients to exhibit negative symptoms, and they are also more likely to follow a chronic, deteriorating course (Atalay & Atalay, 2006; Moriarty, et al., 2001).

Gender differences in the age of onset and symptomatic expression of schizophrenia can be interpreted in several ways. The alternatives fall into two types of hypotheses. One ap- proach assumes that schizophrenia is a single disorder and that its expression varies in men and women. A common, geneti- cally determined vulnerability to schizophrenia might be ex- pressed differently in men than in women. Mediating factors that might account for this difference could be biological dif- ferences between men and women—perhaps involving certain hormones—or different environmental demands, such as the timing and form of stresses associated with typical male and female sex roles. An alternative approach suggests that there are two qualitatively distinct subtypes of schizophrenia: one with an early onset that affects men more often than women, and another with a later onset that affects women more often than men. Both approaches assume a combination of geneti- cally determined predisposition to disorder with the onset of symptoms being triggered by environmental events. The avail- able evidence does not allow us to favor one of these explana- tions over the other (Haefner et al., 1998; Taylor & Langdon, 2006).

© Barbara Smaller/www.cartoonbank.com

360 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

Cross-Cultural Comparisons Schizophrenia has been observed in virtually every culture that has been subjected to careful analysis. Although it is a universal disorder, the frequency of schizophrenia is not constant around the world. The annual incidence of schizophrenia—that is, the number of new cases appearing in any given year—varies from one country to the next. Reported estimates range from 8 to 43 cases per 100,000 people (McGrath, 2005). Urban populations have higher rates than rural areas, but incidence is not related to a country’s economic status (Saha et al., 2006). As epidemiologists attempt to unravel these differences and explain them, we will learn more about the causes of the disorder.

Substantial cross-cultural differences have also been found with regard to the course of schizophrenia. Two large-scale epi- demiological studies, conducted by teams of scientists working for the World Health Organization (WHO), have drawn consid- erable attention to differences in short- and long-term outcome for schizophrenia in the third world and industrialized countries (Sartorius, 2007). The International Pilot Study of Schizophrenia (IPSS) began in the 1960s and was conducted in nine countries in Europe, North America, South America, Africa, and Asia. It included 1,200 patients who were followed for 15 to 25 years after their initial hospitalization. The Collaborative Study on the Determinants of Outcome of Severe Mental Disorders (DOS) was begun a few years later in six of the same countries that par- ticipated in the IPSS, plus four others. The DOS study included more than 1,500 patients. Both the IPSS and DOS projects ex- amined rural and urban areas in both Western and non-Western countries. For purposes of cultural comparison, the countries were divided into those that were “developing” and those that were already “developed” on the basis of prevailing socioeco- nomic conditions. All the interviewers were trained in the use of a single, standardized interview schedule, and all employed the same sets of diagnostic criteria.

The IPSS results indicated that patients who exhibited char- acteristic signs and symptoms of schizophrenia were found in all

of the study sites. Comparisons of patients across research centers revealed more similarities than differences in clinical symptoms at the time of entry into the study, which was always an active phase of disorder that required psychiatric treatment. The IPSS investigators found that clinical and social outcomes were signifi- cantly better for schizophrenic patients in developing countries than in developed countries, such as the United States, England, and Russia. The DOS study confirmed those results (Hopper, et al., 2007).

The WHO studies provide compelling support for the conclusion that, although the frequency of schizophrenia varies around the world, it is expressed in terms of similar symptoms in different cultures. Most experts believe that the more favor- able clinical outcome that was observed in India and Nigeria is a product of the greater tolerance and acceptance extended to people with psychotic symptoms in developing countries. This conclusion is consistent with evidence regarding the relation- ship between frequency of relapse and patterns of family com- munication, which we consider later in this chapter in the section on expressed emotion. These cross-cultural data certainly testify to the important influence of culture in shaping the experience and expression of psychotic symptoms (Thakker & Ward, 1998; Whaley & Hall, 2009).

Causes Having considered the defining characteristics of schizophrenia, ways in which it has been classified, and some basic informa- tion regarding its distribution within the general population, we now review the evidence regarding factors that might contrib- ute to the development of the disorder, as well as its course and outcome.

Biological Factors Many of the early investigators who defined schizophrenia at the beginning of the twentieth century believed that the disorder was the product of a biological dysfunction. At that time very little

TABLE 13.1 Typical Gender Differences in Schizophrenia Variable Men Women

Age of onset Earlier (18–25) Later (25–35)

Premorbid functioning; adjustment

Poor social functioning; more schizotypal traits Good social functioning; fewer schizotypal traits

Typical symptoms More negative symptoms; more withdrawn and passive

More hallucinations and paranoia; more emotional and impulsive

Course More often chronic; poorer response to treatment Less often chronic; better response to treatment

Source: Based on J. M. Goldstein. 1995. The Impact of Gender on Understanding the Epidemiology of Schizophrenia. In M.V. Seeman, Ed., Gender and Psychopathology. Washington, DC: American Psychiatric Press: 159–199.

schizophrenia spectrum and other psychotic disorders CHAPTER 13 361

was known about human genetics or the biochemistry of the brain. Research in the areas of molecular genetics and the neu- rosciences has progressed at an explosive rate in the past decade. Much of what we know today about the biological substrates of schizophrenia has emerged from advances that have taken place in other sciences.

GENETICS The role of genetic factors has been studied more ex- tensively with regard to schizophrenia than with any other type of mental disorder. The existing data are based on sophisticated methods that have been refined over many years. The cumulative weight of this evidence points clearly toward some type of ge- netic influence in the transmission of this disorder (Pogue-Geile & Gottesman, 2007).

FAMILY STUDIES Figure 13.1 illustrates the lifetime risk for schizophrenia for various types of relatives of a person with schizophrenia. This figure was created by pooling data from 40 European studies that were published between 1920 and 1987 (Gottesman, 1991). All of the studies employed conservative di- agnostic criteria for the disorder.

Consider the data for first-degree relatives and second-degree relatives. On average, siblings and children share 50 percent of their genes with the schizophrenic proband; nieces, nephews, and cousins share only 25 percent. The lifetime morbid risk for schizophrenia is much greater among first-degree relatives than it is among second-degree relatives. The risk in the second-degree relatives is greater than the 1 percent figure that is typically reported for people in the general population. As the degree of genetic similarity increases between an individual and a schizo- phrenic patient, the risk to that person increases. The family history data are consistent with the hypothesis that the transmis- sion of schizophrenia is influenced by genetic factors (Goldstein,

et al., 2010). They do not prove the point, however, because fam- ily studies do not separate genetic and environmental events (see Chapter 2).

TWIN STUDIES Several twin studies have examined concordance rates for schizophrenia. The results of these studies are also sum- marized in Figure 13.1. The average concordance rate for MZ twins is 48 percent, whereas the comparable figure for DZ twins is 17 percent. One study from Finland found a concordance rate of 46 percent among MZ twins and only 9 percent among DZ twins (Cannon, et al., 1998). Although the specific rates vary somewhat from study to study, all of the published reports have found that MZ twins are significantly more likely than DZ twins to be concordant for schizophrenia. This pattern suggests strongly that genetic factors play an important role in the development of the disorder.

It should also be pointed out, however, that none of the twin studies of schizophrenia has found a concordance rate that even approaches 100 percent, which would be expected if genetic fac- tors were entirely responsible for schizophrenia. Thus, the twin studies also provide compelling evidence for the importance of environmental events. Some people, like Marsha in the case presented earlier, apparently inherit a predisposition to the de- velopment of schizophrenia. Among that select group of vulner- able individuals, certain environmental events must determine whether a given person will eventually exhibit the full-blown symptoms of the disorder.

ADOPTION STUDIES Studies of children who were adopted away from their biological parents and reared by foster families provide further evidence regarding the impact of genetic and environmental factors. The first adoption study of schizophre- nia began by identifying records for a group of 49 children who were born between 1915 and 1945 while their mothers were

FIGURE 13.1 Rates of schizophrenia among relatives of patients with schizophrenia

Lifetime risk of developing schizophrenia increases as a function of percent of genes shared with a per- son who has been diagnosed with the disorder. Source: Based on data from I.I. Gottesman (1991). Schizophrenia genesis: The origins of madness, p. 96. Freeman.

Spouses of patients

Uncles and aunts

Nephews and nieces

Grandchildren

Children

Brothers and sisters

Children

Fraternal twins of opposite sex

Parents

Identical twins

10 20 30 40 500

Offspring – both parents with SCZ

General population

Lifetime Risk (percent)

362 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

hospitalized for schizophrenia (Heston, 1966). All the children were apparently normal at birth and were separated from their mothers within three days of birth. To rule out possible exposure to the environment associated with the mother’s psychosis, any child who had been in contact with maternal relatives was ex- cluded from the study. A control group of children was selected using the admission records of foundling homes where many of the target children had originally been placed. These children were matched to the patients’ children on a number of variables, including age, sex, type of eventual placement, and amount of time spent in institutions.

Most of the offspring were successfully located and inter- viewed when they were in their mid-thirties. Five of the adult offspring of schizophrenic mothers received a diagnosis of schizo- phrenia. Correcting for the fact that most of the participants were still within the period of risk for the disorder, this resulted in a lifetime morbidity risk for schizophrenia of 16.6 percent in the target group, which is almost exactly the rate observed among children of schizophrenic parents who were raised by their bio- logical parents (see Figure 13.1). In contrast, none of the adult offspring in the control group received a diagnosis of schizophre- nia. Because the only difference between the two groups was the genetic relationship between the target offspring and their schizo- phrenic biological mothers, these data indicate that genetic fac- tors play a role in the development of the disorder. Several other adoption studies have been concerned with schizophrenia, and all reach the same conclusion as Heston’s original report (Pogue- Geile & Gottesman, 2007).

THE SPECTRUM OF SCHIZOPHRENIC DISORDERS Results from adoption and twin studies also provide interesting clues re- garding the boundaries of the concept of schizophrenia. Several types of psychotic disorders and personality disorders resemble schizophrenia in one way or another, including schizoaffective disorder, delusional disorder, and schizotypal personality disorder (discussed in Chapter 9). Are these conditions a reflection of the same genetically determined predisposition as schizophrenia, or are they distinct disorders caused by different forces? If they are genetically related, then investigators should find that the biolog- ical relatives of schizophrenic adoptees are more likely to exhibit these conditions as well as schizophrenia. The overall pattern of re- sults does suggest that vulnerability to schizophrenia is sometimes expressed as schizophrenia-like personality traits and other types of psychoses (Tarbox & Pogue-Geile, 2011; van Snellenberg & de Candia, 2009).

MOLECULAR GENETICS The combined results from twin and adoption studies indicate that genetic factors are involved in the transmission of schizophrenia. This conclusion does not imply, however, that the manner in which schizophrenia develops is well understood. We know little beyond the fact that genetic factors are involved in some way. The mode of transmission has not been identified. Most clinical scientists believe that schizophrenia is a polygenic characteristic, which means that it is the product of a

reasonably large number of genes rather than a single gene (see Chapter 2).

One of the most exciting areas of research on genetics and schizophrenia focuses on molecular genetics (see Research Meth- ods in Chapter 14 for an explanation of this process). Studies of this type are designed to identify specific genes that are responsi- ble for the disorder (or some important components of the disor- der). So far, investigators have not been able to identify any genes that account for a major proportion of the heritability of schizo- phrenia, but they have found several genes that apparently have a very small but measurable impact (Mitchell & Porteous, 2011; Owen, et al., 2010; Sanders, et al., 2008). Supporters of the search for specific genes involved in the transmission of schizo- phrenia contend that the absence of more definitive discoveries is not surprising when we consider the complexity of this process and the magnitude of the search. They feel that the search for a particular gene that causes schizophrenia will simply take more time (Cannon, 2010).

One specific gene that has attracted considerable re- search attention is associated with the production of catechol O-methyltransferase (COMT), which is an enzyme that is in- volved in breaking down the neurotransmitter dopamine. The COMT gene is located on chromosome 22, a region that has been linked to schizophrenia. People who possess a specific form of the COMT gene (called the Val allele) seem to have a small but consistently increased risk for schizophrenia (Glatt, Faraone, & Tsuang, 2003). Scientists believe that this gene may increase risk for schizophrenia by affecting dopamine transmission in the prefrontal cortex of the brain, with the net effect being impaired cognitive ability (Prata, et al., 2009; van Haren, Bakker, & Kahn, 2008) (see later section on working memory and vulnerability to schizophrenia).

PREGNANCY AND BIRTH COMPLICATIONS People with schizophrenia are more likely than the general population to have been exposed to various problems during their mother’s pregnancy and to have suffered birth injuries. Problems during pregnancy include the mother’s contracting various types of dis- eases and infections. Birth complications include extended labor, breech delivery, forceps delivery, and the umbilical cord wrapped around the baby’s neck. These events may be harmful, in part, because they impair circulation or otherwise reduce the availabil- ity of oxygen to developing brain regions. Birth records indicate that the mothers of people who later develop schizophrenia ex- perienced more complications at the time of labor and delivery (Cannon, Jones, & Murray, 2002).

It is not clear whether the effects of pregnancy and birth complications interact with genetic factors. They may produce neurodevelopmental abnormalities that result in schizophrenia regardless of family history for the disorder. Conversely, a fetus that is genetically predisposed to schizophrenia may be more sus- ceptible to brain injury following certain kinds of obstetric dif- ficulties (Khandaker, et al., 2013; Walker, et al., 2004).

schizophrenia spectrum and other psychotic disorders CHAPTER 13 363

Dietary factors may also play a role in the etiology of the disorder. Severe maternal malnutrition in the early months of pregnancy leads to an increased risk of schizophrenia among the offspring. This conclusion is based on a study of medical and psy- chiatric records of people who were born in the western part of the Netherlands between 1944 and 1946 (Susser, et al., 1996). The German blockade of ports and other supply routes in this area led to a severe famine at the end of World War II. People who were conceived during the worst months of the famine were twice as likely to develop schizophrenia than were people whose mothers became pregnant at other times, including the early months of the famine. These results, coupled with more recent findings, suggest that prenatal nutritional deficiencies may dis- rupt normal development of the fetal nervous system (Abel et al., 2010; Insel, et al., 2008).

VIRAL INFECTIONS Some speculation has focused on the potential role that viral infections may play in the etiology of schizophrenia (Brown & Derkits, 2010). One indirect line of support for this hypothesis comes from studies indicating that people who develop schizophrenia are somewhat more likely than other people to have been born during the winter

months (McGrath & Welham, 1999). Some clinicians inter- pret this pattern to mean that, during their pregnancies, the mothers were more likely to develop viral infections, which are more prevalent during the winter. Exposure to infection pre- sumably interferes with brain development in the fetus. This possibility has received considerable attention in the research literature and remains an important topic of debate (Clarke, et al., 2009).

NEUROPATHOLOGY One important step toward understand- ing the etiology of schizophrenia would be to identify its neuro- logical underpinnings. If people with schizophrenia suffer from a form of neurological dysfunction, shouldn’t it be possible to observe differences between the structure of their brains and those of other people? This is a challenging task. Scientists have invented methods to create images of the living human brain (see Chapter 4). Some of these procedures provide static pictures of various brain structures at rest, just as an X-ray provides a photographic image of a bone or some other organ of the body. More recently, sophisticated methods have enabled scientists to create functional images of the brain while a person is perform- ing different tasks. Studies using these techniques have produced evidence indicating that a number of brain areas are involved in schizophrenia (Fitzsimmons, et al, 2013; Reichenberg & Harvey, 2007). You may want to review the description of brain struc- tures in Chapter 2 (Figure 2.3) before reading the next sections of this chapter.

STRUCTURAL BRAIN IMAGING Many investigations of brain structure in people with schizophrenia have employed magnetic resonance imaging (MRI; see Chapter 4 for an explanation of this process). The disorder is not associated with abnormalities in one specific brain region or in one particular type of nerve cell. Rather, it seems to affect many different regions of the brain and the ways in which they connect or communicate with each other (Shepherd, et al., 2012). Most MRI studies have reported a decrease in total volume of brain tissue among schizophrenic patients. Another consistent finding is that some people with schizophrenia have mildly to moderately enlarged lateral ven- tricles, the cavities on each side of the brain that are filled with cerebrospinal fluid.

These differences seem to reflect a natural part of the dis- order rather than a side effect of treatment with antipsychotic medication. In fact, some studies have found enlarged ventricles in young schizophrenic patients before they have been exposed to any form of treatment (Steen, et al., 2006). Some studies have also found enlarged ventricles prior to the onset of symptoms. The structural changes seem to occur early in the development of the disorder and therefore may play a role in the onset of symp- toms (DeLisi, 2008; Weinberger & McClure, 2002).

The temporal lobes have also been studied extensively us- ing MRI scans. Several studies have reported decreased size of the hippocampus, the parahippocampus, the amygdala, and the

The devastating consequences of war include severe nutritional deficien- cies, such as those suffered in Somalia by this mother and her 4-year-old son. The offspring of women who are pregnant during serious famines may be more likely to develop schizophrenia as they reach adulthood.

364 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

thalamus, all of which are parts of the limbic system (Price, et al., 2006). These areas of the brain (see Figure 13.2) play a cru- cial role in the regulation of emotion as well as the integration of cognition and emotion. Decreased size of these structures in the limbic area of the temporal lobes may be especially noticeable on the left side of the brain, which plays an important role in the control of language.

Many questions remain to be answered regarding the relation between structural brain abnormalities and schizophrenia. Does the pattern reflect a generalized deterioration of the brain, or is it the result of a defect in specific brain sites? We don’t know. Is the presence of enlarged ventricles and cortical atrophy con- sistently found in some subset of schizophrenic patients? Some investigators have reported an association between this type of

MRI scans from four identical twin pairs discordant for schizo- phrenia showing varying degrees of increased ventricular size in the twin with the disorder compared to the twin who is well.

FIGURE 13.2 Structures of the Brain Implicated in Schizophrenia Structural imaging procedures indicate reduced size of temporal lobe structures, such as the hippocampus and amygdala, among some patients with schizophrenia.

Amygdala

Temporal lobe

Frontal lobes

Hippocampus

schizophrenia spectrum and other psychotic disorders CHAPTER 13 365

neuropathology and other factors, such as negative symptoms, poor response to medication, and absence of family history of the disorder. These are all interesting possibilities, but none has been firmly established.

FUNCTIONAL BRAIN IMAGING In addition to static pictures of brain structures, clinical scientists use techniques that pro- vide dynamic images of brain functions. One dynamic brain imaging technique, known as positron emission tomography (PET), can reflect changes in brain activity as the person re- sponds to various task demands. Visual stimulation will pro- duce increased cerebral blood flow in the visual cortex; people performing a simple motor task exhibit increased flow in the motor cortex. Functional MRI is another tool that can be used to observe brain activity. The results of studies using these tech- niques suggest dysfunction in various neural circuits, includ- ing some regions of the prefrontal cortex (see Figure 13.3) and several regions in the temporal lobes (Bonner-Jackson, et al., 2005; Whalley, et al., 2012). The problems seem to involve activities within, as well as integration between, a variety of functional circuits rather than a localized abnormality in one region of the brain.

The role of neurological abnormalities in schizophrenia has been highlighted by a study of identical twins conducted by in- vestigators at the National Institute of Mental Health (NIMH). Participants included 27 pairs of twins discordant for schizophre- nia and 13 pairs that were concordant for the disorder. Changes in brain structure, measured by MRI, and changes in brain func- tion, measured by cerebral blood flow, were prominent in the

twins who had developed schizophrenia. Their well co-twins also exhibited more neurological impairment than a group of normal control participants, but these abnormalities were less marked than those found in the probands. Among discordant monozygotic pairs, the schizophrenic twin typically had the smaller hippocampus and smaller amygdala. The schizophrenic twins always showed reduced frontal lobe activity compared with their unaffected co-twins. Results for enlarged ventricles were less consistent. In general, neurological dysfunction seemed to be associated with the overall severity of the disorder rather than being indicative of an etiologically distinct subgroup of patients (Bridle, et al., 2002).

GENERAL CONCLUSIONS The primary conclusion that can be drawn from existing brain imaging studies is that schizophre- nia is associated with diffuse patterns of neuropathology. The most consistent findings point toward structural as well as func- tional irregularities in the frontal cortex and limbic areas of the temporal lobes, which play an important role in cognitive and emotional processes. The neural network connecting limbic ar- eas with the frontal cortex may be fundamentally disordered in schizophrenia.

Speculation regarding disruptions in neural circuitry must also be tempered with caution. Evidence of neuropathology does not seem to be unique to schizophrenic patients. Many patients with other psychiatric and neurological disorders show similar changes in brain structure and function. Furthermore, a spe- cific brain lesion has not been identified, and it is unlikely that

FIGURE 13.3 Areas of Brain Function Implicated in Schizophrenia Neural circuits in the dorsolateral prefrontal cortex may function improperly in schizophrenia.

Dorsolateral Prefrontal Cortex

366 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

one will be found. It is unlikely that a disorder as complex as schizophrenia will be traced to a single site in the brain. The various symptoms and cognitive deficits that have been observed in schizophrenic patients may be linked to a host of subtle dis- ruptions in neurological functions (Csernansky & Cronenwett, 2008; Green, 2001).

It should also be emphasized that brain imaging procedures are not diagnostically meaningful tests for mental disorders. For example, an MRI showing enlarged ventricles does not prove that a patient has schizophrenia. Brain imaging procedures have iden- tified interesting group differences, but they do not predict the presence of schizophrenia for individuals. The group differences that have been observed are very subtle in comparison to the levels of neuropathology found in disorders such as Alzheimer’s disease and Huntington’s disease (see Chapter 14). Some schizo- phrenic patients do not show abnormalities in brain structure or function.

A dramatic example of this point was found in the NIMH study of discordant MZ twins. In one pair, the well twin was a successful businessman who had never had any problems with mental disorder. His twin brother had been severely impaired with schizophrenia for 20 years. The well twin had ventricles that were five times larger than those of the schizophrenic twin. Thus, we should approach all these hypotheses with caution and skepticism.

NEUROCHEMISTRY The neurological underpinnings of schizo- phrenia may not take the form of changes in the size or organiza- tion of brain structures. They may be even more subtle, involving alterations in the chemical communications among neurons within particular brain circuits.

THE DOPAMINE HYPOTHESIS Scientists have proposed various neurochemical theories to account for the etiology of schizophre- nia. The most influential theory, known as the dopamine hypoth- esis, focuses on the function of specific dopamine pathways in the limbic area of the brain. The original version of the dopamine hypothesis proposed that the symptoms of schizophrenia are the product of excessive levels of dopaminergic activity. This hypoth- esis grew out of attempts to understand how antipsychotic drugs improve the adjustment of many schizophrenic patients. Animals who receive doses of antipsychotic drugs show a marked increase in the production of dopamine. In 1963, it was suggested that antipsychotic drugs block postsynaptic dopamine receptors. The presynaptic neuron recognizes the presence of this blockade and increases its release of dopamine in a futile attempt to override it (Carlsson & Lindqvist, 1963).

If the dopamine system is dysfunctional in schizophrenic pa- tients, what is the specific form of this problem? One possibility is that certain neural pathways have an elevated sensitivity to do- pamine because of increased numbers of postsynaptic dopamine receptors. The potency of various types of antipsychotic drugs is specifically related to their ability to block one type of dopa- mine receptor, known as D2 receptors. Imaging studies of brain

functions in patients with schizophrenia have found elevated lev- els of dopamine functioning in the striatum (Howes et al., 2009).

INTERACTIONS OF MULTIPLE NEUROTRANSMITTERS A dysregulation and exaggerated response of certain dopamine pathways is certainly involved in schizophrenia, at least for some patients. On the other hand, experts now agree that sev- eral other neurotransmitters also play an important role. A neurochemical model focused narrowly on dopamine fails to explain many different aspects of the disorder, including the following: Some patients do not respond positively to drugs that block dopamine receptors; the effects of antipsychotic drugs require several days to become effective, but dopamine blockage begins immediately; and research studies that exam- ined the by-products of dopamine in cerebrospinal fluid were inconclusive at best.

Current neurochemical hypotheses regarding schizophre- nia focus on a broad array of neurotransmitters (Carlsson et al., 2001). Special interest has been focused on serotonin pathways since the introduction of a new class of antipsychotic drugs such as clozapine (Clozaril) that are useful in treating patients who were resistant to standard antipsychotic drugs. (See the section on treatment.) These “atypical” antipsychotics produce a strong blockade of serotonin receptors and only a weak blockade of D2 receptors. This pattern leads to speculation that the neurochemical substrates of schizophrenia may involve a complex interaction be- tween serotonin and dopamine pathways in the brain (Downar & Kapur, 2008).

Brain imaging studies that point to problems in the prefron- tal cortex have also drawn attention to glutamate and GABA (gamma-aminobutyric acid), the two principal neurotransmitters in the cerebral cortex (Wassef, Baker, & Kochan, 2003). Gluta- mate is an excitatory neurotransmitter, and GABA is an inhibi- tory neurotransmitter. As in the case of serotonin, hypotheses regarding the role of glutamate and GABA focus on their interac- tions with dopamine pathways, especially those connecting tem- poral lobe structures with the prefrontal and limbic cortexes.

Social Factors There is little question that biological factors play an important role in the etiology of schizophrenia, but twin studies also pro- vide compelling evidence for the importance of environmental events. The disorder is expressed in its full-blown form only when vulnerable individuals experience some type of environ- mental event, which might include anything from nutritional variables to stressful life events (Howes et al., 2004; Walker, et al., 2004). What sorts of nongenetic events interact with genetic factors and other biological factors to produce schizophrenia? We will review some of the hypotheses that have been proposed and studied.

SOCIAL CLASS One general indicator of a person’s status within a community’s hierarchy of prestige and influence is social class. People from different social classes are presumably exposed to

schizophrenia spectrum and other psychotic disorders CHAPTER 13 367

different levels of environmental stress, with those people in the lowest class being subjected to the most hardships. More than 70 years ago, social scientists working in Chicago found that the highest prevalence of schizophrenia was found in neighborhoods of the lowest socioeconomic status (Faris & Dunham, 1939). Many research studies have subsequently confirmed this finding in several other geographic areas (Boydell & Murray, 2003). The evidence supporting an inverse relationship between social class and schizophrenia is substantial.

There are two ways to interpret the relationship between social class and schizophrenia. One holds that harmful events associated with membership in the lowest social classes, which might include many factors ranging from stress and social isola- tion to poor nutrition, play a causal role in the development of the disorder. This is often called the social causation hypothesis. It is also possible, however, that low social class is an outcome rather than a cause of schizophrenia. Those people who develop schizophrenia may be less able than others to complete a higher level education or to hold a well-paying job. Their cognitive and social impairments may cause downward social mobility. In other words, regardless of the social class of their family of origin, many schizophrenic patients may gradually drift into the lowest social classes. This view is sometimes called the social selection hypothesis.

Research studies have found evidence supporting both views. The social selection hypothesis is supported by studies that have compared the occupational roles of male schizophrenic patients with those of their fathers. The patients are frequently less suc- cessful than their fathers, whereas the opposite pattern is typical of men who do not have schizophrenia (Jones et al., 1993). It is also true, however, that a disproportionately high percentage of the fathers of schizophrenic patients were from the lowest social class (Harrison et al., 2001). This finding is consistent with the social causation hypothesis.

MIGRANT STUDIES Higher rates of schizophrenia have also been found repeatedly among people who have migrated to a new country (Cantor-Graae & Selton, 2005). Several influential stud- ies of this sort focused on African Caribbean people who moved to the United Kingdom from Jamaica, Barbados, and Trinidad. Risk for schizophrenia in these migrant groups was found to be several times higher than the risk observed in the native-born U.K. population. It was also much higher than the risk observed among people living in the migrants’ countries of origin. Subsequent studies demonstrated that the effect is not unique to the United Kingdom. Larger effects are reported for migrants from developing rather than developed countries, and they are also larger for mi- grants from countries where the majority population is black. One possible explanation for this phenomenon is that social adversity increases risk for schizophrenia. Migrants tend to settle in urban areas where they may be exposed to discrimination and other forms of disadvantage (Fearon & Morgan, 2006; Weiser et al., 2008).

In general, the evidence regarding socioeconomic status and schizophrenia indicates that the disorder is, to a certain extent,

influenced by social factors. Adverse social and economic cir- cumstances may increase the probability that persons who are genetically predisposed to the disorder will develop its clinical symptoms (van Os & McGuffin, 2003).

Psychological Factors Most of the attention devoted to psychological factors and schizo- phrenia has focused on patterns of behavior and communication within families. Research evidence indicates that family interac- tions and communication problems are not primarily responsible for the initial appearance of symptoms. Disturbed patterns of communication among family members do not cause people to develop schizophrenia. This knowledge is important to parents of schizophrenic patients. They experience enough emotional an- guish without also being made to feel that something they did or said was the primary cause of their child’s problems.

EXPRESSED EMOTION The family environment does have a significant impact on the course (as opposed to the original on- set) of schizophrenia. Studies of this effect are concerned with the adjustment of patients who have already been treated for schizo- phrenic symptoms. This effect was discovered by people who were interested in the adjustment of patients who were discharged after being treated in a psychiatric hospital. Men with schizophrenia were much more likely to return to the hospital within the next nine months if they went to live with their wives or parents than if they went to live in other lodgings or with their siblings. The patients who relapsed seemed to react negatively to some feature of their close relationship with their wives or mothers.

Subsequent research confirmed this initial impression (Vaughn & Leff, 1976). Relatives of schizophrenic patients were

Criticism and hostility can increase the risk of relapse for some patients with schizophrenia. Conversely, warmth and family support can serve as a protective factor.

368 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

interviewed prior to the patients’ discharge from the hospital, and many of the relatives made statements that reflected nega- tive or intrusive attitudes toward the patient. These statements were used to create a measure of expressed emotion (EE). For example, many of the relatives expressed hostility toward the pa- tient or repeatedly criticized the patient’s behavior. The following comments, made by the stepfather of a young man with schizo- phrenia, illustrate generalized, hostile criticisms of the patient’s behavior. These comments would be considered to be high in ex- pressed emotion.

INTERVIEWER: What seemed different about Stephen’s behavior? STEPFATHER: Everything and anything. In other words, he’s the type of person, you don’t tell him, he tells you. INTERVIEWER: You say that he spent time in a juvenile facility? STEPFATHER: Yeah. This kid is a genuine con artist, believe me. I spent time in the service and I’ve been around con artists. This kid is a first-class, genuine con artist, bar none.

(Leff & Vaughn, 1985, p. 42)

Other family members appeared to be overprotective or too closely identified with the patient. These phenomena are also rated as being high in expressed emotion. Of course, a certain amount of worrying and concern should be expected from a par- ent whose child has developed a severe disorder such as schizo- phrenia. In the assessment of expressed emotion, relatives were considered to be emotionally overinvolved if they reported re- sponses such as extreme anxiety or exaggerated forms of self-sac- rifice. For example, the following exchange illustrates emotional overinvolvement (high EE) by the mother of a 24-year-old male patient who had his first onset of the disorder when he was 22:

MOTHER: He talked to me a lot—because I was his therapist—the person he shared with more than anybody else. He involves me, ruminates with me, because I allow him to do it. INTERVIEWER: How frequently? MOTHER: He would do it constantly. He would do it as much as I would be there with him. INTERVIEWER: Once or twice a week? MOTHER: No, it happened daily. All the time I was with him, particularly in the last four or five months. He would talk to me for hours at a time, worrying and sharing how bad he felt, reporting to me every change in mood or feeling from 5-minute to 5-minute period.

(Leff & Vaughn, 1985, p. 51)

Patients who returned to live in a home with at least one mem- ber who was high in EE were more likely than patients from low EE families to relapse in the first nine months after discharge. This result has been replicated many times (Marom et al., 2005). Approximately

half of schizophrenic patients live in families that would be rated as being high in EE. Average relapse rates—defined primarily in terms of the proportion of patients who show a definite return of positive symptoms in the first year following hospital discharge—are 52 per- cent for patients in high EE families and 22 percent for patients in low EE families. Among the various types of comments that can con- tribute to a high EE rating, criticism is usually most strongly related to patients’ relapse (Hooley & Gotlib, 2000).

High EE seems to be related, at least in part, to relatives’ knowledge and beliefs about their family member’s problems. Relatives find it easier to accept the most obvious positive symp- toms as being the product of a mental disorder (Brewin et al., 1991). They show less tolerance toward negative symptoms, such as avolition and social withdrawal, perhaps because the patient may appear to be simply lazy or unmotivated.

UNDERSTANDING FAMILY ATTITUDES The influence of ex- pressed emotion is not unique to schizophrenia. Patients with mood disorders, eating disorders, panic disorder with agoraphobia, and obsessive–compulsive disorder are also more likely to relapse following discharge if they are living with a high EE relative (Mik- lowitz, 2004). In fact, EE is an even better predictor of outcome for mood disorders and eating disorders than it is for schizophrenia (Butzlaff & Hooley, 1998). The extension of this phenomenon to other disorders should not be taken to mean that it is unimportant or that the social context of the family is irrelevant to our under- standing of the maintenance of schizophrenia (see Research Meth- ods). It may indicate, however, that this aspect of the causal model is shared with other forms of psychopathology. The specific nature of the person’s symptoms may hinge on the genetic predisposition.

Cross-cultural evidence suggests that high EE may be more common in Western or developed countries than in non-Western or developing countries (Kymalainen & Weissman de Mamani, 2008). This observation might help explain why the long-term course of schizophrenia is typically less severe in developing coun- tries. Some speculation has focused on family members’ attitudes and beliefs: People in developing countries may be more tolerant of eccentric behavior among their extended family members. These attitudes may create environments similar to those found in low EE homes in the West. An alternative view places greater emphasis on the culturally determined relationships between patients and other members of their families (Aguilera et al., 2010). Studies of Mexi- can American families suggest that prosocial aspects of interactions between patients and their families can enhance family cohesion and decrease the stigma associated with serious mental disorders. In some cultures, family warmth serves as a protective factor and reduces the probability of patients’ relapse (López et al., 2004).

We must be cautious to avoid a narrow view of this phenom- enon. The concept of expressed emotion raises extremely sensi- tive issues for family members, who have too frequently been blamed for the problems of people with schizophrenia. Expressed emotion is not the only factor that can influence the course of a schizophrenic disorder. Some patients relapse in spite of an

schizophrenia spectrum and other psychotic disorders CHAPTER 13 369

understanding, tolerant family environment. Furthermore, re- search studies have shown that the relationship between patients’ behavior and relatives’ expressed emotion is a transactional or re- ciprocal process. In other words, patients influence their relatives’ attitudes at the same time that relatives’ attitudes influence pa- tients’ adjustment. Persistent negative attitudes on the part of rel- atives appear to be perpetuated by a negative cycle of interactions in which patients play an active role (Goldstein et al., 1997).

Interaction of Biological and Environmental Factors A useful causal model for schizophrenia must include the in- teraction of genetic factors and environmental events. The

heterogeneous nature of the disorder, in terms of symptoms as well as course, also suggests that schizophrenia should be ex- plained in terms of multiple pathways (Tandon, Keshavan, & Nasrallah, 2008). Some forms of the disorder may be the prod- uct of a strong genetic predisposition acting in combination with relatively common psychosocial experiences, such as stressful life events or disrupted communication patterns. For other people, relatively unusual circumstances, such as severe malnutrition during pregnancy, may be responsible for neurodevelopmental abnormalities that eventually lead to the onset of psychotic symp- toms in the absence of genetic vulnerability (Gilmore, 2010).

Various kinds of environmental events have been linked to the etiology of schizophrenia. Some may operate in interaction with

RESEARCH methods

Comparison Groups: What Is Normal?

Research studies in the field of psychopathology typically involve comparisons among two or more groups of par-ticipants. One group, sometimes called “cases,” includes people who already meet the diagnostic criteria for a particular mental disorder, such as schizophrenia. Comparison groups are composed of people who do not have the disorder in ques- tion. This approach is sometimes called the case control design because it depends on a contrast between cases and control participants. If the investigators find a significant difference between groups, they have demonstrated that the dependent variable is correlated with the disorder (see Research Methods in Chapter 2). They hope to conclude that they have identified a variable that is relevant to understanding the etiology of this condition. Causal inferences are risky, however, in correlational research. Our willingness to accept these conclusions hinges in large part on whether the investigators selected an appropriate comparison group.

People conducting correlational research must make every effort to identify and test a group of people who are just like the cases except that they do not have the disorder in question (Gehl- bach, 1988). This typically means that the people in both groups should be similar with regard to such obvious factors as age, gender, and socioeconomic background. If the investigators find differences between people who have the disorder and those who do not, they want to attribute those differences to the disorder itself. Two main types of comparison groups are used in psychopathology research: people with no history of mental disorder, sometimes called “normal participants,” and people who have some other form of mental disorder, sometimes called “patient controls.”

Selecting normal comparison groups is not as simple as it might seem. In fact, researchers must make several basic decisions. Does “normal” mean that the person has never had the disorder

in question, or does it mean a complete absence of any type of psychopathology? Should people be included as normal control participants if they have a family history of the disorder, even though they do not have the disorder themselves?

A second research strategy involves comparing patients with one type of disorder to those who have another form of psy- chopathology. Investigators usually employ this strategy to de- termine whether the variable in question is specifically related to the disorder that they are studying. Are enlarged lateral ventricles or family communication problems unique to people with schizophrenia? Lack of specificity may raise questions about whether this variable is related to the cause of the disorder. It might suggest that this particular variable is, instead, a general consequence of factors such as hospitalization, which the patient control group has also experienced.

Many of the causal factors that we have discussed in this chapter are not unique to schizophrenia. For example, expressed emo- tion predicts relapse among patients with mood disorders as well as among those with schizophrenia. Should this result be taken to mean that EE does not play an important role in the development of schizophrenia? Not necessarily. The answer to this question depends on the specific causal model that is being considered (Garber & Hollon, 1991). All forms of psychopathol- ogy depend on the interaction of multiple factors spanning biological, social, and psychological systems. Some of these may be specific to the disorder being studied, and others may be general. The development of schizophrenia may depend on a specific genetically determined predisposition. The environmen- tal events that are responsible for eventually causing vulnerable people to express this disorder might be nonspecific. The fact that similar factors influence people with mood disorders should not be taken to mean that EE is not an important factor in the complex chain of events that explain schizophrenia.

370 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

the genotype for schizophrenia; others may be sufficient to produce the disorder on their own. Considerable speculation has focused re- cently on biological factors, such as viral infections and nutritional deficiencies. Psychosocial factors, such as adverse economic circum- stances, may also be involved. These events may be particularly harmful to people who are genetically predisposed to the disorder.

The Search for Markers of Vulnerability Schizophrenia is often a chronic disorder, and it can be difficult to treat. Many clinicians believe that the outcome of treatment pro- grams would be more positive if the intervention could be started earlier, before the person has become severely disturbed and before the disorder has had a prolonged impact on the person’s social and

educational experiences (Jacobs et al., 2012). One way of approach- ing that problem would be to focus on the earliest overt signs of the disorder, subtle patterns of disturbed thinking and speaking, which are often accompanied by a progressive pattern of social withdrawal. These behavioral manifestations—symptoms of the prodromal phase—are often evident before the onset of full-blown psychotic symptoms. In fact, the DSM-5 workgroup considered introducing a new diagnostic category, called attenuated psychosis syndrome, for this purpose (Carpenter & van Os, 2011; Tsuang et al., 2013). It was eventually relegated to Section III of the manual (Conditions for Further Study) because the field trials indicated that it cannot be identified reliably and the research evidence does not support its va- lidity (see Thinking Critically About DSM-5).

THINKING CRITICALLY about DSM-5

Attenuated Psychosis Syndrome Reflects Wishful Rather Than Critical Thinking

For many years, mental health professionals have hoped to find a way to intervene early with people who are vulner-able to schizophrenia and prevent the onset of full-blown psychosis. In this spirit, the workgroup on schizophrenia for DSM-5 considered a proposal for a new disorder to be called at- tenuated psychosis syndrome (APS) (Carpenter & van Os, 2011; Tsuang et al., 2013). In order to qualify for a diagnosis of APS, the person would need to show at least one psychotic symptom in an attenuated form. For example, the person might view other people as being untrustworthy, but he would not have paranoid delusions. He might speak in a vague or unfocused manner without showing disorganized speech. Furthermore, the person would be aware of the difference between the reality and fantasy and able to conform to accepted norms for social behavior (i.e., show “intact reality testing”). What does this definition mean? In layperson’s terms, APS describes people who fall somewhere in that poorly defined zone between unusual and psychotic.

The motivation to define APS as a formal diagnostic category was well intentioned. Considerable research has been devoted to identifying prodromal symptoms of schizophrenia and signs of high-risk for the disorder. If we start with a group of people who have already developed full-blown psychosis and follow them back in time, before the development of their obvious symptoms, it’s true that their experiences could be described in terms of the defining features of APS (Lencz et al., 2004). But, we also have to ask several other important questions before this disorder could serve any useful purpose. Is it possible to identify reliably the vague level of attenuated symptoms that serve as diagnostic cri- teria for APS? Based on the results of the DSM-5 field trials, the answer to that question is clearly “no” (Freedman et al., 2013).

Second, let’s assume that we can identify reliably people who show symptoms of APS, how many will go on to develop full- blown symptoms of psychosis (i.e., convert to schizophrenia)?

The answer is “some, but not very many” (Fusar-Poli et al., 2013; Phillips, 2013).

Third, if people who qualify for a diagnosis of APS are treated in some way (most likely with the same drugs that are used to treat full-blown psychosis), will their progression to more severe symptoms be prevented? The answer is “occasionally, but not very often”

Finally, what risks are associated with being treated for APS? Several have been considered (Yung, 2011). Of course one form of risk is associated with the negative consequences of labeling (see section on Labeling Theory in Chapter 4). Even more impor- tant, however, are the potentially harmful effects of antipsychotic medication. Substantial evidence indicates that there are long- term neurological consequences to taking these drugs (Whita- ker, 2010). These include intrusive motor side effects, which are sometimes irreversible, as well as increased risk of obesity and the many health consequences that follow from that condition. Would you want your friend or sibling to be exposed to these risks simply because they are behaving in an unusual way (espe- cially if those behaviors are extremely difficult to identify)?

The proponents of APS based their proposal on wishful think- ing rather than sound research data. Perhaps to their credit, the members of the workgroup recommended that APS be relegated to Section III, with other proposed disorders that require further study. But APS should have been omitted from the manual entirely. The danger is that many of the proposals that have been listed in this appendix eventually made their way into the main body of the DSM-5 (see premenstrual dysphoric disorder and binge eating disorder). The appendix is a staging area where diagnostic fads go to incubate until sufficient pressure can be mobilized to force their incorporation into the main body of the diagnostic manual. APS is a poorly defined diagnostic construct. It could easily lead to much more harm than good, and it doesn’t belong anywhere in DSM-5.

schizophrenia spectrum and other psychotic disorders CHAPTER 13 371

Another promising option for identifying people before they develop over symptoms of schizophrenia would focus on the genetic predisposition to the disorder. Studies of molecular genetics will obviously be part of that answer, if several genes are found to be responsible for the disorder. The search for more precise ways to identify people before they become psychotic may also hinge on the ability to identify vulnerability mark- ers, which have also been called endophenotypes (Gottesman & Gould, 2003; Greenwood et al., 2007). An endophenotype is a component or trait that lies somewhere on the pathway between the genotype, which lays the foundation for the disorder, and full-blown symptoms of the disorder. It can be measured with precise laboratory procedures of many kinds, but it cannot be seen by the unaided eye.

If we are looking for signs of vulnerability—or endopheno- types—that can be detected among individuals who are geneti- cally predisposed to schizophrenia, where should we look? What form will these signs take? Is it possible to detect signs of vulner- ability among individuals who approach the threshold for devel- oping schizophrenia spectrum disorders but have not exhibited any kind of overt symptoms? This issue has attracted considerable attention, but we don’t have firm answers to these questions.

People who are vulnerable to schizophrenia might be identi- fied by developing measures that could detect the underlying bio- logical dysfunction or by developing sensitive measures of their subtle eccentricities of behavior. The range of possible markers is, therefore, quite large.

Assume that we have selected a specific measure, such as a biochemical assay or a psychological test, and we are interested in knowing whether it might be useful in identifying people who are vulnerable to schizophrenia. What criteria should a vulnerability marker fulfill? First, the proposed marker must distinguish be- tween people who already have schizophrenia and those who do not. Second, it should be a stable characteristic over time. Third, the proposed measure of vulnerability should identify more peo- ple among the biological relatives of schizophrenic patients than among people in the general population. For example, it should be found among the discordant MZ twins of schizophrenic pa- tients, even if they don’t exhibit any symptoms of schizophrenia. Finally, the proposed measure of vulnerability should be able to predict the future development of schizophrenia among those who have not yet experienced a psychotic episode (Braff, Schork, & Gottesman, 2007; Snitz, MacDonald, & Carter, 2006).

Although reliable measures of vulnerability have not been identified, they are being actively pursued by many investigators with a wide variety of measurement procedures. In the following pages we will outline some of the psychological procedures that have been shown to be among the most promising.

WORKING MEMORY IMPAIRMENT Many investigators have pursued the search for signs of vulnerability by looking at mea- sures of cognitive performance in which schizophrenic patients differ from other people. Some of these studies have focused on

cognitive tasks that evaluate information processing, working memory, and attention/vigilance (Forbes et al., 2009; Green et al., 2004).

Considerable emphasis has been focused on one aspect of cognitive functioning known as working memory, or the ability to maintain and manipulate information for a short period of time. Working memory can be broken down into several more specific processes. Some of these involve memory buffers that provide short-term storage for visual and verbal information. The most important processes in working memory involve a central executive component that is responsible for the manipulation and transformation of data that are held in the storage buffers. Many studies have reported that people with schizophrenia are impaired in their ability to perform laboratory tasks that depend on this central executive component of working memory (Barch, 2005; Gold et al., 2010).

The identification of deficits in working memory is particu- larly interesting with regard to schizophrenia because it links to other evidence regarding brain functions and this disorder. Pro- cesses that are associated with central executive processing are associated with brain activity located in the dorsolateral area of the prefrontal cortex (see Figure 13.3) which seems to be dys- functional in schizophrenia. Neurochemical hypotheses regarding schizophrenia are also relevant in this regard because the dopa- mine neurotransmitter system plays a crucial role in supporting activities involved in working memory (Goldman-Rakic, Muly, & Williams, 2000).

Working memory problems seem to be a stable characteristic of patients with schizophrenia; they do not fluctuate over time (Cannon et al., 2002). Furthermore, these cognitive deficits are found with increased prevalence among the unaffected first- degree relatives of schizophrenic persons, including discordant MZ twins (Sitskoom et al., 2004). Finally, children who later re- ceive a diagnosis of schizophrenia are more likely to have been im- paired on tests of verbal working memory than are their siblings who do not develop the disorder. Therefore, measures of working memory fulfill several of the criteria for an index of vulnerability. The research indicates that problems in working memory may be useful signs of vulnerability to schizophrenia (Barch, 2005).

EYE-TRACKING DYSFUNCTION Another promising line of work involves impairments in eye movements—specifically, dif- ficulty in tracking the motion of a pendulum or a similarly oscil- lating stimulus while the person’s head is held motionless. When people with schizophrenia are asked to track a moving target, like an oscillating pendulum, with their eyes, a substantial number of them show dysfunctions in smooth-pursuit eye movement (Levy et al., 2010). Instead of reproducing the motion of the pendulum in a series of smooth waves, their tracking records show frequent interruptions of smooth-pursuit movements by numerous rapid movements. Examples of normal tracking records and those of schizophrenic patients are presented in Figure 13.4. Only about 8 percent of normal people exhibit the eye-tracking dysfunctions

372 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

illustrated in part (C) of Figure 13.4, although some studies have reported higher figures.

Approximately 50 percent of the first-degree relatives of schizophrenic persons show similar smooth-pursuit impairments (Calkins, Iacono, & Ones, 2008; Hong et al., 2008). The over- all pattern of results seen in people with schizophrenia and their families suggests that poor tracking performance may be associ- ated with the predisposition to schizophrenia. That conclusion be- comes even more interesting in light of evidence from additional studies suggesting that tracking ability is stable over time, influ- enced by genetic factors, and found among people who exhibit features associated with schizotypal personality disorder (Good- ing, Miller, & Kwapil, 2000; O’Driscoll & Callahan, 2008).

It is not yet possible to identify people who are specifically predisposed to the development of schizophrenia, but research studies have identified potential vulnerability markers. The real test, of course, will center around predictive validity. Can any of these measures, such as working memory deficits or smooth- pursuit eye-tracking impairment, predict the later appearance of schizophrenia in people whose scores indicate possible vulner- ability? High-risk studies will be useful in providing this type of evidence.

Treatment Schizophrenia is a complex disorder that often must be treated over an extended period of time. Clinicians must be concerned about the treatment of acute psychotic episodes as well as the pre- vention of future episodes. A multifaceted approach to treatment is typically required. Antipsychotic medication is the primary mode of treatment for this disorder. Because many patients re- main impaired between episodes, long-term care must often in- volve the provision of housing and social support. People with impaired social and occupational skills need special types of training. The treatment of schizophrenia requires attention on all of these fronts and is necessarily concerned with the coopera- tive efforts of many types of professionals (Lehman et al., 2004). Schizophrenia also takes its toll on families. The Getting Help section at the end of this chapter discusses some of the resources available for patients and families.

Antipsychotic Medication The many different forms of medication that are used to treat patients with schizophrenia can be divided into two broad

categories. The first generation of drugs began to be introduced in the 1950s, and a second generation swept into practice in the 1990s. Both kinds of medication are in standard use today.

The first generation of antipsychotic drugs—also called clas- sical or traditional antipsychotics—was discovered accidentally in the early 1950s. Early reports of success in treating chronic psychotic patients quickly led to the widespread use of these drugs, such as chlorpromazine (Thorazine), in psychiatric hos- pitals throughout Europe and the United States (Shen, 1999). This process quickly changed the way in which schizophrenia was treated. Large numbers of patients who had previously been in- stitutionalized could be discharged to community care (but see Chapter 18 on the effects of deinstitutionalization).

Several related types of drugs were developed in subsequent years. They are called antipsychotic drugs because they have a relatively specific effect—to reduce the severity of psychotic symptoms. Some beneficial effects on problems such as agitation and hostility may be noticed within a week after the patient be- gins taking antipsychotic medication, but it usually takes two or three weeks before improvement is seen with regard to psychotic symptoms (Kutscher, 2008). Positive symptoms, such as halluci- nations, respond better to antipsychotic medication than negative symptoms, such as alogia and diminished emotional expression. Viewed from the patient’s perspective, medication allows them to be less bothered or preoccupied by troublesome thoughts and perceptual experiences. In other words, they are able to distance themselves from their positive symptoms, even though the medi- cation seldom eliminates hallucinations and delusional beliefs completely.

Double-blind, placebo-controlled studies have confirmed the effectiveness of antipsychotic medication in the treatment of patients who are acutely disturbed. Literally thousands of stud- ies have addressed this issue over a period of more than 40 years (Haddad et al., 2009; Sharif et al., 2007). Most studies find that about half of the patients who receive medication are rated as be- ing much improved after four to six weeks of treatment. Further improvements may continue beyond that point for some patients. In contrast, patients treated with placebos exhibit much smaller rates of improvement, and many of them actually deteriorate.

Unfortunately, a substantial minority of schizophrenic pa- tients, perhaps 25 percent, do not improve on antipsychotic drugs (Conley & Kelly, 2001). Another 30 to 40 percent might be con- sidered partial responders: Their condition improves, but they do not show a full remission of symptoms. Investigators have not

FIGURE 13.4 Eye-Tracking Patterns This illustration contrasts smooth-pursuit eyetracking patterns of normal subjects with those of schizophrenic patients. Part (A) shows the actual target. Part (B) illustrates the pattern for people without schizophrenia, and part (C) shows the pattern for people with schizophrenia. Source: Based on Levy DL, Holzman PS, Matthysse S, Mendell NR. Eye tracking dysfunction and schizophrenia: A critical perspective. Schizophrenia Bulletin. 1993; 19: 461–536.

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schizophrenia spectrum and other psychotic disorders CHAPTER 13 373

been able to identify reliable differences between patients who improve on medication and those who do not. Some experts have suggested that treatment-resistant patients may have more promi- nent negative symptoms, greater disorganization, and more evi- dence of neurological abnormalities (Elkis, 2007).

MAINTENANCE MEDICATION After patients recover from acute psychotic episodes, there is a high probability that they will have another episode. The relapse rate may be as high as 65 to 70 percent in the first year after hospital discharge if patients discon- tinue medication. Continued treatment with antipsychotic drugs can reduce this rate to approximately 40 percent (Takeuchi et al., 2012). Therefore, patients with schizophrenia are encouraged to continue taking medication after they recover from psychotic episodes, although usually at a lower dose. Unfortunately, may patients stop taking medication, often to avoid unpleasant side effects (Falkai, 2008).

MOTOR SIDE EFFECTS Antipsychotic drugs produce several unpleasant side effects. They come in varying degrees and affect different patients in different ways. The most obvious and trou- blesome are called extrapyramidal symptoms (EPS) because they are mediated by the extrapyramidal neural pathways that connect the brain to the motor neurons in the spinal cord. These symp- toms include an assortment of neurological disturbances, such as muscular rigidity, tremors, restless agitation, peculiar involuntary postures, and motor inertia. EPS may diminish spontaneously af- ter the first few months of treatment, but some patients continue to experience EPS for many years.

Prolonged treatment with antipsychotic drugs can lead to the development of a more severe set of motor symptoms called tardive dyskinesia (TD). This syndrome consists of abnormal

involuntary movements of the mouth and face, such as tongue protrusion, chewing, and lip puckering, as well as spasmodic movements of the limbs and trunk of the body. The latter in- clude writhing movements of the fingers and toes and jiggling of the legs, as well as jerking movements of the head and pel- vis. Taken as a whole, this problem is quite distressing to patients and their families. The TD syndrome is induced by antipsychotic treatment, and it is irreversible in some patients, even after the medication has been discontinued. In fact, in some patients, TD becomes worse if antipsychotic medication is withdrawn (Eber- hard, Lindström, & Levander, 2006; Lauterbach et al., 2001).

SECOND-GENERATION ANTIPSYCHOTICS Several additional forms of antipsychotic medication began to be introduced in the 1990s. Although some clinicians hailed their development as a “second revolution” in the care of patients with schizophre- nia, many experts now recognize that this claim has been over- stated (Lieberman, 2006; Miyamoto et al., 2012). These drugs are frequently called atypical antipsychotics because they are less likely than the classical antipsychotics to produce unpleasant mo- tor side effects. The best known of the atypical drugs, clozapine (Clozaril), has been used extensively throughout Europe since the 1970s. The second generation of antipsychotic medications also includes risperidone (Risperdal), olanzapine (Zyprexa), quetiap- ine (Seroquel), and several other drugs that have recently become available or are waiting for approval by the FDA. Some of these drugs are listed in Table 13.2.

The good news about second-generation antipsychotics is that they are at least as effective as traditional drugs for the treat- ment of positive symptoms of schizophrenia (Lieberman et al., 2005; Sikich et al., 2008), and they are useful in maintenance treatment to reduce the risk of relapse (Wang et al., 2010). They

TABLE 13.2 Examples of Medications Used to Treat Schizophrenic Disorders

Modes of Action

Selected Side Effects Selected Receptors

EPS Weight Gain D2 5HT2A

Drug Class Generic Name (trade name)

First-generation antipsychotics chlorpromazine (Thorazine) 11 1 11 1

haloperidol (Haldol) 1111 1 1111 1

Second-generation Antipsychotics

clozapine (Clozaril) 1/2 1111 11 1111

risperidone (Risperdal) 11 11 111 11111

olanzapine (Zyprexa) 1 1111 111 1111

quetiapine (Seroqul) 1/− 11 11 111

amisulpride (Solian)* 1 11 1111 2

D2 = dopamine receptors; 5HT2a = serotonin receptors.

*Amisulpride is not available in the United States, but it has been used for more than 15 years in France (Leucht et al., 2002).

Source: S. Kapur and G. Remington. 2001. Atypical Antipsychotics: New Directions and New Challenges in the Treatment of Schizophrenia. Annual Review of Medicine; 52: 503–517.

374 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

of evidence regarding the treatment of schizophrenia from the Cochrane Library at its website: www.cochrane.org.

Psychosocial Treatment Several forms of psychological treatment have proved to be ef- fective for schizophrenic patients. These procedures address a wide range of problems that are associated with the disorder. Psychological treatments have usually concentrated on long-term strategies rather than the resolution of acute psychotic episodes (Kopelowicz, Liberman, & Zarate, 2002). More recently, several investigators have begun to explore the use of psychosocial inter- ventions in combination with antipsychotic medication for first- episode patients (Grawe et al., 2006; Penn et al., 2005).

FAMILY-ORIENTED AFTERCARE Studies of expressed emotion have inspired the development of innovative family-based treat- ment programs. Family treatment programs attempt to improve the coping skills of family members, recognizing the burdens that people often endure while caring for a family member with a chronic mental disorder. Patients are maintained on antipsy- chotic medication on an outpatient basis throughout this pro- cess. There are several different approaches to this type of family intervention. Most include an educational component that is de- signed to help family members understand and accept the nature of the disorder (see Getting Help on page 376). One goal of this procedure is to eliminate unrealistic expectations for the patient, which may lead to harsh criticism. Behavioral family manage- ment also places considerable emphasis on the improvement of communication and problem-solving skills, which may enhance the family members’ ability to work together and thereby mini- mize conflict.

are also less likely to produce tardive dyskinesia. One review of several outcome studies reported that 13 percent of patients tak- ing second-generation antipsychotics developed tardive dyski- nesia, compared to 32 percent patients taking first-generation antipsychotics (Correll & Shenk, 2008). The combination of beneficial effects on positive symptoms and reduced motor side effects makes these forms of medication a reasonable choice in the treatment of schizophrenia.

The bad news is that, contrary to initial claims, second- generation antipsychotics are not significantly more effective for treating negative symptoms (Buckley & Stahl, 2007; Murphy et al., 2006). They also produce additional side effects, and some of them are serious. For example, many of the atypical antipsy- chotics lead to weight gain and obesity (Das et al., 2012). These problems increase the person’s risk for additional medical prob- lems, such as diabetes, hypertension, and coronary artery disease. These adverse reactions lead many patients to discontinue their medication, thus increasing risk of relapse. One influential study compared one first-generation antipsychotic with four types of second-generation drugs. The investigators reported that 74 per- cent of patients stopped taking their prescribed medication be- fore the end of the 18-month treatment period (Lieberman et al., 2005). Poor compliance was found for all of the different drugs. The bottom line is that various kinds of antipsychotic medication are beneficial for patients with schizophrenia, but they all have weaknesses, and none is without adverse side effects.

All antipsychotic medications—both first and second- generation forms—act by blocking dopamine receptors in the cortical and limbic areas of the brain (Factor, 2002). They also affect a number of other neurotransmitters, including sero- tonin, norepinephrine, and acetylcholine. Table 13.2 includes a comparison of two first-generation and five second-generation antipsychotic drugs in terms of their ability to block specific types of dopamine and serotonin receptors. Most second-gener- ation antipsychotics produce a broader range of neurochemical actions in the brain than do the traditional drugs, which act primarily on dopamine receptors. Clozapine and olanzapine, for example, produce a relatively strong blockade of serotonin receptors and a relatively weaker blockade of dopamine recep- tors (Richelson, 1999). This increased affinity of some atypical drugs for serotonin receptors might explain why they can have a beneficial effect on symptoms of schizophrenia while producing fewer motor side effects (EPS). This hypothesis is contradicted, however, by the modes of action associated with a newer form of atypical drug, amisulpride, which does not affect serotonin receptors (Leucht, Kissling, & Davis, 2009). Neurochemical differences between different forms of antipsychotic drugs are not completely understood and are currently the topic of inter- esting debate (Richtand et al., 2007).

Further progress in the pharmacological treatment of schizo- phrenia will undoubtedly produce new drugs that have varying mechanisms of neurochemical action. The rate of progress in this field is very rapid. You can obtain regularly updated reviews

Patients and families respond in many creative ways to the presence of mental disorder. Brandon Staglin (left) has struggled with schizophrenia for several years. His parents founded an annual Music Festival for Mental Health, which has raised millions of dollars for mental health charities and research.

schizophrenia spectrum and other psychotic disorders CHAPTER 13 375

(such as recognizing the perspectives of other people and apprais- ing social contexts). It is designed for use with people who are also taking antipsychotic medication and have already recovered from active symptoms of psychosis but nevertheless continue to exhibit signs of cognitive disability. Patients spend many hours practicing computerized cognitive exercises. Several weeks after beginning cognitive training exercises, they also participate in an extended series of small group exercises (interpreting verbal mes- sages, recognizing others’ emotions, maintaining conversations, and so on). One large-scale two-year outcome study compared patients who received cognitive enhancement therapy with pa- tients in a control group who received enhanced supportive ther- apy. Those who received CET showed more improvement with regard to performance on measures of cognitive performance, so- cial cognition, overall social adjustment, and employment (Eack et al., 2011). Thus, in the context of ongoing treatment with an- tipsychotic medication, cognitive therapy can be beneficial for patients with schizophrenia.

ASSERTIVE COMMUNITY TREATMENT The treatment of a chronic disorder such as schizophrenia clearly requires an exten- sive range of comprehensive services that should be fully inte- grated and continuously available. Assertive community treatment (ACT) is a psychosocial intervention that is delivered by an inter- disciplinary team of clinicians (DeLuca, Moser, & Bond, 2008; Stein & Santos, 1998). They provide a combination of psycho- logical treatments—including education, support, skills training, and rehabilitation—as well as medication. Services are provided on a regular basis throughout the week and during crisis periods (any time of day and any day of the week). The program repre- sents an intensive effort to maintain seriously disordered patients in the community and to minimize the need for hospitalization. It differs from more traditional outpatient services in its assertive

Several empirical studies have evaluated the effects of fam- ily interventions. Most have found reductions in relapse rates for people receiving family treatment (Barrowclough & Lobban, 2008; Girón et al., 2010). Family-based treatment programs can delay relapse, but they do not necessarily prevent relapse in the long run. In the case of a disorder such as schizophrenia, which is often chronic, difficult decisions have to be made about priorities and the availability of services. Family-based programs can have a positive effect, but we need to find more efficient and more ef- fective ways to integrate this aspect of treatment into an overall treatment program.

SOCIAL SKILLS TRAINING Many patients who avoid relapse and are able to remain in the community continue to be impaired in terms of residual symptoms. They also experience problems in social and occupational functioning. For these patients, drug therapy must be supplemented by psychosocial programs that ad- dress residual aspects of the disorder. The need to address these problems directly is supported by evidence that shows that defi- cits in social skills are relatively stable in schizophrenic patients and relatively independent of other aspects of the disorder, in- cluding both positive and negative symptoms.

Social skills training (SST) is a structured, educational ap- proach to these problems that involves modeling, role playing, and the provision of social reinforcement for appropriate be- haviors (Heinssen, Liberman, & Kopelwicz, 2000). A general description of this type of approach to treatment is provided in Chapter 3. Controlled-outcome studies indicate that, in combination with neuroleptic medication, SST leads to im- proved performance on measures of social adjustment. It is not clear, however, that SST has any beneficial effects on relapse rates (Pilling et al., 2002b). That result may not be surpris- ing in light of evidence regarding the course of this disorder, which suggests that various aspects of outcome, including symptom severity and social adjustment, tend to be relatively independent.

COGNITIVE THERAPY One area of treatment that has received much greater emphasis in recent years is the use of various forms of cognitive therapy for schizophrenia (Rathod & Turkington, 2005; Temple & Ho, 2005). In some cases, these interventions have focused on the use of standard cognitive therapy procedures that are designed to help patients evaluate, test, and correct dis- torted ways of thinking about themselves and their social envi- ronments. Other forms of cognitive treatment have become more specialized and are aimed specifically at cognitive deficits that are particularly evident in schizophrenia.

One example of a specialized treatment program is cognitive enhancement therapy (CET) for schizophrenia (Hogarty et al., 2004). This is a comprehensive, integrated program aimed at the improvement of cognitive abilities, including those that are con- cerned with performance on laboratory tasks (such as attention, working memory, and problem solving) as well as social cognition

Many people have made remarkable achievements in spite of suffering from schizophrenia. Tom Harrell has been named jazz trumpeter of the year three times by Downbeat Magazine. He hears disturbing auditory hallucinations, but they disappear when he is playing music.

376 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

patients experience recurrent phases of active psychosis. Brief periods of hospitalization (usually two or three weeks) are often beneficial during these times.

Some patients are chronically disturbed and require long- term institutional treatment. Social learning programs, some- times called token economies, can be useful for these patients (Dickerson, Tenhula, & Green-Paden, 2005). In these programs specific behavioral contingencies are put into place for all of the patients on a hospital ward. The goal is to increase the fre- quency of desired behaviors, such as appropriate grooming and participation in social activities, and to decrease the frequency of undesirable behaviors, such as violence or incoherent speech. Staff members monitor patients’ behavior throughout the day. Each occurrence of a desired behavior is praised and reinforced by the presentation of a token, which can be exchanged for food or privileges, such as time to watch television. Inappropriate be- haviors are typically ignored, but occasional punishment, such as loss of privileges, is used if necessary. Carefully structured inpa- tient programs, especially those that follow behavioral principles, can have important positive effects for chronic schizophrenic patients.

approach to the provision of services: Members of an ACT team go to the consumer rather than expecting the consumer to come to them.

Outcome studies indicate that ACT programs can effectively reduce the number of days that patients spend in psychiatric hospitals, while improving their level of functioning (Nordentoft et al., 2010; Thornicroft & Susser, 2001). One study found that only 18 percent of the people in the ACT group were hospital- ized during the first year of treatment compared to 89 percent of the people in the control group. ACT is an intensive form of treatment that requires a well-organized and extensive network of professional services. In spite of the expense that is required to maintain this kind of program, empirical studies indicate that it is more cost-effective than traditional services provided by community mental health centers (Lehman et al., 1999). Reduc- tion in costs of inpatient care offsets the expense of the ACT program.

INSTITUTIONAL PROGRAMS Although schizophrenic persons can be treated with medication on an outpatient basis, vari- ous types of institutional care continue to be important. Most

getting HELP

Schizophrenia can be a devastating condition for patients and their families. Fortunately, the past two decades have seen many important advances in treatment for this disor- der. Perhaps no other disorder requires such an extensive array of services, ranging from medication and short-term inpatient care to long-term residential facilities and psychosocial help for family members. An extremely useful book, Coping with Schizophrenia: A Guide for Families, written by Kim Mueser and Susan Gingrich, offers sound advice on a variety of crucial topics. For example, the authors discuss various forms of antipsychotic drugs, their side effects, their use in preventing relapse, and ways to respond to a patient’s reluctance to continue taking nec- essary medication. They outline available community resources that help patients and their families deal with acute episodes, as well as the long-term challenges of residual symptoms, occupa- tional difficulties, and housing needs.

Another excellent resource is The Family Face of Schizophrenia, by Patricia Backlar, who is a mental health ethicist and also the mother of a son who suffers from schizophrenia. This book in- cludes a series of seven stories about people who have struggled

with this disorder and the often confusing and sometimes in- adequate array of mental health services that are available in many communities. Each story is followed by a commentary that includes advice for patients and their families (e.g., how to obtain insurance benefits for treatment, how to find a missing mentally ill family member, how to cope with suicidal risks, and how to navigate legal issues that can arise in caring for someone with a serious mental disorder). Anyone who must cope with a psychotic disorder will benefit from reading these books carefully.

The National Alliance for the Mentally Ill (NAMI) is an extremely influential grassroots support and advocacy organization that has worked tirelessly to improve the quality of life for patients and their families. It has more than 1,000 state and local affiliates throughout the United States. NAMI is committed to increasing access to community-based services such as housing and rehabili- tation for people with severe mental disorders. The address for its website is www.nami.org. It is a comprehensive source of informa- tion regarding all aspects of severe mental disorders (especially schizophrenia and mood disorders), including referral to various types of support groups and professional service providers.

schizophrenia spectrum and other psychotic disorders CHAPTER 13 377

People who meet the diagnostic criteria for schizophrenia exhibit symptoms that represent impairments across a broad array of cognitive, perceptual, and interpersonal functions. These symptoms can be roughly divided into three types. Positive symptoms include hallucinations and delusions. Negative symptoms include diminished emotional expres- sion, alogia, avolition, and social withdrawal. Symptoms of disorganization include verbal communication problems and disorganized behavior.

DSM-5 requires evidence of a decline in the person’s social or occupational functioning, as well as the presence of disturbed behavior over a continuous period of at least six months for a diagnosis of schizophrenia.

Related psychotic disorders include delusional disorder, brief psychotic disorder, and schizoaffective disorder.

The onset of schizophrenia is typically during adolescence or early adulthood. The disorder can follow different patterns over time. Some people recover fairly quickly from schizophrenia, whereas others deteriorate progressively after the initial onset of symptoms.

The lifetime prevalence of schizophrenia is approximately 1 per- cent in the United States and Europe. Men are 30 to 40 percent more likely than women to be affected by the disorder, and its onset tends to occur at an earlier age in males. Male patients are more likely than female patients to exhibit negative symptoms, and they are also more likely to follow a chronic, deteriorating course.

Genetic factors clearly play a role in the development of schizo- phrenia. Risk for developing the disorder is between 10 percent and 15 percent among first-degree relatives of schizophrenic patients. Concordance rates are approximately 48 percent in MZ twins compared to only 17 percent in DZ pairs. Twin and adop- tion studies indicate that the disorder has variable expressions, sometimes called the schizophrenia spectrum. Schizophrenia spectrum disorders include schizotypal personality disorder as well as other psychotic disorders.

A specific brain lesion has not been identified, and it is unlikely that a disorder as complex as schizophrenia will be traced to a single site in the brain. Structural images of schizophrenic patients’ brains reveal enlarged ventricles as well as decreased size of parts of the limbic system. Studies of brain metabolism and blood flow have identified functional changes in the frontal lobes, temporal lobes, and basal ganglia in many persons with schizophrenia.

The discovery of antipsychotic medication stimulated interest in the role of neurochemical factors in the etiology of schizo- phrenia. The dopamine hypothesis provided the major unify- ing theme in this area for many years, but it is now consid- ered too simple to account for the existing evidence. Current neurochemical hypotheses regarding schizophrenia focus on a broad array of neurotransmitters, with special emphasis on serotonin.

Several social and psychological factors have been shown to be related to the disorder. Social class is inversely related to the prevalence of schizophrenia. People who have migrated to a new country are at greater risk for schizophrenia, suggesting the possible influence of social adversity and discrimination.

Patients from families that are high in expressed emotion are more likely to relapse than those from low EE families. Expressed emotion is the product of an ongoing interaction between patients and their families, with patterns of influence flowing in both directions.

The evidence regarding etiology supports a diathesis-stress model. It should be possible to develop vulnerability markers that can identify individuals who possess the genetic predis- position to the disorder. Promising research in this area is con- cerned with a broad range of possibilities, including laboratory measures of working memory and smooth-pursuit eye-tracking movements.

The central aspect of treatment for schizophrenia is antipsy- chotic medication. These drugs help to resolve acute psychotic episodes. They can also delay relapse and improve the level of patients’ functioning between episodes. Unfortunately, they often produce troublesome side effects, and a substantial minority of schizophrenic patients are resistant to antipsychotic medication.

Various types of psychosocial treatments also provide important benefits to schizophrenic patients and their families. Prominent among these are family-based treatment for patients who have been stabilized on medication following discharge from the hospital. Social skills training can also be useful in improving the level of patients’ role functioning.

13 Summary

378 CHAPTER 13 schizophrenia spectrum and other psychotic disorders

13.1 Why do clinical scientists say that schizophrenia is a “het- erogeneous” disorder? Schizophrenia is a disorder of many faces. It is defined by an ex- tremely diverse set of symptoms that involve distortions of cognition, perception, and emotion. Finally, it can follow many different pat- terns over time . . . (see page 349).

13.2 How should long-term outcome be measured in schizo- phrenia? It must be viewed from a broad spectrum. Important dimensions in- clude the presence and severity of symptoms, the ability to function socially and occupationally, the need for housing and other social services, and the impact on other family members . . . (see page 358).

13.3 Why are some personality disorders considered to be schizophrenia spectrum disorders? Some of the symptoms of schizotypal personality disorders represent less severe forms of psychotic symptoms. The first-degree relatives of patients with schizophrenia are more likely than other people to qualify for a di- agnosis of certain types of personality disorders . . . (see page 362).

13.4 Why can’t we use brain imaging to diagnose schizophrenia? They are useful research tools, but they have not identified any as- pects of brain structure or function that are unique to people with this disorder . . . (see pages 363–365).

13.5 What characteristics would define a useful marker of vul- nerability to schizophrenia? It should be found more frequently among schizophrenic patients and their first-degree relatives, it should be stable over time, and it should be present prior to the onset of psychotic symptoms . . . (see page 371).

13.6 What aspects of schizophrenia are addressed most di- rectly by psychosocial treatments? Problems with social cognition (ways of thinking about oneself and others) and interpersonal relationships are often the targets of psychological interventions, which are designed to be used in conjunction with antipsychotic medication . . . (see page 375).

critical thinking review

The Big Picture

key terms anhedonia 354 antipsychotic drugs 372 avolition 354 brief psychotic disorder 357 delusions 352

delusional disorder 357 diminished emotional

expression 353 disorganized speech 354 expressed emotion (EE) 368

hallucinations 352 negative symptoms 351 positive symptoms 351 prodromal phase 350 schizoaffective disorder 358

schizophrenia 349 vulnerability marker 371

14

neurocognitive disorders

380 CHAPTER 14 neurocognitive disorders

14 The Big Picture learning objectives

14.1 What is the difference between cognitive problems in

anxiety and those seen in major neurocognitive disorders?

14.2 In what ways is delirium different from dementia?

14.3 Is memory impairment the only indication that a person

is developing a major neurocognitive disorder?

14.4 Why is depression in an elderly person sometimes confused with dementia?

14.5 How could education help to reduce a person’s

risk for major neurocognitive disorder?

14.6 What are the most difficult problems faced by people caring

for a person with a major neurocognitive disorder?

Most of us are absent-minded from time to time. We may forget to make a phone call, run an errand, or complete an assignment. Occasional lapses of this sort are part of normal experience. Unfortu- nately, some people develop severe and persistent memory problems and other types of cognitive dysfunction that disrupt their everyday activities and interactions with other people. Imagine that you have lived in the same house for many years. You go for a short walk, and then you can’t remember how to get home. Suppose you are shown a photograph of your parents, and you don’t recognize them. These are some of the fundamental cognitive problems discussed in this chapter.

Overview Neurocognitive disorders, including dementia and delirium, are the most frequent disorders found among elderly psychiatric pa- tients. Both conditions involve memory impairments, but they are quite different in other ways. Dementia is a gradually worsen- ing loss of memory and related cognitive functions, including the use of language, as well as reasoning and decision making. It is a clinical syndrome that involves progressive impairment of many

cognitive abilities (Waldemar & Burns, 2009). Delirium is a con- fusional state that develops over a short period of time and is often associated with agitation and hyperactivity. The most important symptoms of delirium are disorganized thinking and a reduced ability to maintain and shift attention (de Lange, Verhaak, & van der Meer, 2013). Delirium and dementia are produced by very different processes. Dementia is a chronic, deteriorating condition that reflects the gradual loss of neurons in the brain. Delirium is usually the result of medical problems, such as infec- tion, or of the side effects of medication. If diagnosed and prop- erly treated, it is typically short-lived. It can, however, result in serious medical complications, permanent cognitive impairment, or death, if the causes go untreated.

Dementia and delirium are listed as Neurocognitive Disor- ders in DSM-5. Cognitive processes, including perception and attention, are related to many types of mental disorders that we have already discussed, such as depression, anxiety, and schizo- phrenia. In most forms of psychopathology, however, the cogni- tive problems are relatively subtle—mediating factors that help us understand the process by which clinical symptoms are pro- duced. In the case of depression, for example, self-defeating biases may contribute to the onset of a depressed mood. These cognitive schemas are not used, however, as part of the diagnostic criteria for major depression in DSM-5. They are not considered to be the central, defining features of the disorder. Problems in working memory may represent vulnerability markers for schizophrenia, but again, they are not considered symptoms of the disorder. In dementia, memory and other cognitive functions are the most obvious manifestations of the problem. They are its defining fea- tures. As dementia progresses, the person’s attention span, con- centration, judgment, planning, and decision making become severely disturbed.

Dementia is often associated with specific identifiable changes in brain tissue. Many times, these changes can be

Confusion and disorientation are common symptoms of neurocognitive disorders. This elderly woman may not have been aware that she was walk- ing in front of a line of riot police sent to control demonstrators in Moscow.

neurocognitive disorders CHAPTER 14 381

remembering things. He believed that he had been able to avoid most problems, however, by writing notes to himself—directions, procedures, and so on. The results of psychological testing and brain imaging procedures, coupled with Jonathan’s own descrip- tion of his experiences and Alice’s account of his impaired perfor- mance at work, led the neurologist to conclude that Jonathan was exhibiting early signs of dementia, perhaps Alzheimer’s disease. He spoke directly to Jonathan regarding his diagnosis and recom- mended firmly that he retire immediately. A malpractice suit would be devastating to his medical practice. Jonathan agreed to retire.

Although Jonathan was no longer able to cope with his de- manding work environment, his adjustment at home was not severely impaired. The changes in his behavior remained relatively subtle for many months. In short conversations, his cognitive problems were not apparent to his friends, who still did not know the real reason for his retirement. His speech was fluent, and his memory for recent events was largely intact, but his comprehension was diminished. Al- ice noticed that Jonathan’s emotional responses were occasionally flat or restricted. At other times, he would laugh at inappropriate times when they watched television programs together. If Alice asked him about his reaction, it was sometimes apparent that Jonathan did not understand the plot of even the simplest television programs.

Alice found that she had to sew labels into Jonathan’s collars to distinguish the clothes that he wore to work in the yard from those that he wore if they were going shopping or out to eat. Jonathan had become increasingly literal minded. If Alice asked him to do something for her, she had to spell out every last de- tail. For example, he began to have trouble selecting his clothes, which had been a source of pride before the onset of his cogni- tive problems. His judgment about what was appropriate to wear in different situations had disappeared altogether.

It had also become difficult for Jonathan to do things that required a regular sequence of actions or decisions, even if they were quite simple and familiar. Routine tasks took longer than before, usually because he got stuck part of the way through an activity. He had, for example, always enjoyed making breakfast

observed only during autopsy, after the patient’s death. For exam- ple, in Alzheimer’s disease, which is one form of neurocognitive disorder, microscopic examination of the brain reveals the pres- ence of an unusual amount of debris called plaque left from dead neurons and neurofibrillary tangles, indicating that the connec- tions between nerve cells had become disorganized. We describe the neuropathology of Alzheimer’s disease later in this chapter.

Due to the close link between neurocognitive disorders and brain disease, patients with these problems are often diagnosed and treated by neurologists—physicians who deal primarily with diseases of the brain and the nervous system. Multidisciplinary clinical teams study and provide care for people with dementia and amnestic disorders. Direct care to patients and their families is usually provided by nurses and social workers. Neuropsycholo- gists have particular expertise in the assessment of specific types of cognitive impairments. This is true for clinical assessments as well as more detailed laboratory studies for research purposes.

The following two case studies illustrate the variety of symp- toms and problems that are included in the general category of dementia. The first case describes the early stages of dementia.

A Physician’s Developing Dementia Jonathan was a 68-year-old physician who had been practicing family medicine for the past 35 years. His wife, Alice, worked as his office manager. A registered nurse, Kathryn, had worked with them for several years. Four months earlier, Alice and Kathryn both noticed that Jonathan was beginning to make obvious er- rors at work. On one occasion, Kathryn observed that Jonathan had prescribed the wrong medication for a patient’s condition. At about the same time, Alice became concerned when she asked Jonathan about a patient whom he had seen the day before. Much to her surprise, he did not remember having seen the pa- tient, despite the fact that he spent almost half an hour with her, and she was a patient whom he had treated for several years. Jonathan’s personality also seemed to change in small but notice- able ways. He seemed uncharacteristically apathetic about daily activities that he and Alice typically enjoyed together. She also found that he had become increasingly self-centered.

Although Alice tried to convince herself that these were iso- lated incidents, she finally decided to discuss them with Kathryn. Kathryn agreed that Jonathan’s memory was failing. He had trouble recognizing patients whom he had known for many years, and had unusual difficulty making treatment decisions. These problems had not appeared suddenly. Over the past year or two, both women had been doing more things for Jonathan than they had ever done in the past. They needed to remind him about things that were parts of his routine practice. As they pieced together various inci- dents, the pattern of gradual cognitive decline became obvious.

Alice talked seriously to Jonathan about the problems that she and Kathryn had observed. He said that he felt fine, but reluc- tantly allowed her to make an appointment for him to be exam- ined by a neurologist, who also happened to be a friend. Jonathan admitted to the neurologist that he had been having difficulty

MyPsychLab VIDEO CASE

Dementia

ALVIN

“That’s one of the real difficulties. There’s no sign that goes off and says, Yes, he’s understanding, or No, he’s not under- standing it.”

Watch the Video Alvin: Dementia on MyPsychLab

As you watch the interview and the day-in-the-life segment, try to identify the various signs of Alvin’s cognitive impairment.

382 CHAPTER 14 neurocognitive disorders

for Alice on weekends. After his retirement, Alice once found him standing in the kitchen with a blank expression on his face. He had made a pot of coffee and some toast for both of them, but he ran into trouble when he couldn’t find coffee cups. That dis- rupted his plan, and he was stymied.

Jonathan’s case illustrates many of the early symptoms of dementia, as well as the ways in which the beginnings of mem- ory problems can severely disrupt a person’s life. The onset of the disorder is often difficult to identify precisely because forgetful- ness increases gradually. Problems are most evident in challenging situations, as in Jonathan’s medical practice, and least noticeable in familiar surroundings.

Changes in emotional responsiveness and personal- ity typically accompany the onset of memory impairment in dementia. In some cases, personality changes may be evident be- fore the development of full-blown cognitive symptoms (Duchek et al., 2007). These personality changes may be consequences of cognitive impairment. Jonathan’s emotional responses may have seemed unusual sometimes because he failed to comprehend aspects of the environment that were obvious to his wife and other people.

Our next case illustrates more advanced stages of demen- tia, in which the person can become extremely disorganized. Memory impairment progresses to the point where the per- son no longer recognizes his or her family and closest friends. People in this condition are unable to care for themselves, and become so disoriented that the burden on others is frequently overwhelming. This case also provides an example of delirium superimposed on dementia. Up to 50 percent of dementia pa- tients admitted to a hospital are also delirious. It is important for the neurologist to recognize the distinction between these conditions because the cause of the delirium (which might be an infection or a change in the patient’s medications) must be treated promptly (Young et al., 2008).

Dementia and Delirium—A Niece’s Terrible Discoveries Mary was an 84-year-old retired schoolteacher who had grown up in the same small rural community in which she still lived. Never married, she lived with her parents most of her life, except for the years when she was in college. Her parents had died when Mary was in her early sixties. After her retirement at age 65, Mary continued living in her parents’ farmhouse. She felt comfortable there, despite its relative isolation, and liked the fact that it had plenty of space for animals, including her dog, which she called “my baby,” several cats, and a few cows that were kept in the pasture behind the house. Mary’s niece, Nancy, who was 45 years old and lived an hour’s drive away, stopped to visit her once every two or three months.

Over the past year, Nancy had noticed that Mary was becom- ing forgetful, as well as more insistent that her routines remain

unchanged. Bills went unpaid—in fact, the telephone had been disconnected for lack of payment—and the mail wasn’t brought in from the roadside box. Nancy had suggested to Mary that she might be better off in a nursing home, but Mary was opposed to that idea.

During her most recent visit, Nancy was shocked to find that conditions at Mary’s home had become intolerable. Most distressing was the fact that some of her animals had died be- cause Mary forgot to feed them. The dog’s decomposed body was tied to its house, where it had starved. Conditions inside the house were disgusting. Almost 30 cats lived inside the house, and the smell was unbearable. Mary’s own appearance was quite disheveled. She hadn’t bathed or changed her clothes for weeks. Nancy contacted people at a social service agency, who arranged for Mary’s admission to a nursing home. Mary became furious, refusing to go and denying that there was anything wrong with her own home. Nancy was soon declared her legal guardian because Mary was clearly not competent to make deci- sions for herself.

Mary grew progressively more agitated and belligerent dur- ing the few weeks that she lived at the nursing home. She was occasionally disoriented, not knowing where she was or what day it was. She shouted and sometimes struck people with her cane. She had trouble walking, a problem that was compounded by vi- sual and spatial judgment difficulties. After she fell and broke her hip, Mary was transferred to a general hospital.

Mary became delirious in the hospital, apparently as a result of medication she was given for her injury. She appeared to be having visual hallucinations and often said things that did not make sense. These periods of incoherence fluctuated in severity throughout the course of the day. During her worse moments, Mary did not respond to her name being spoken, and her speech was reduced primarily to groans and nonsense words. This clouding of consciousness cleared up a few days after her medication was changed. She became less distractible and was once again able to carry on brief conversations. Unfor- tunately, her disorientation became more severe while she was immobilized in the hospital. When her hip eventually healed, she was moved to a psychiatric hospital and admitted to the geriatric ward.

Although Mary was no longer aware of the date or even the season of the year, she insisted that she did not have any prob- lems with her mind. For the first six weeks at the psychiatric hos- pital, she would be surprised that she was not in her own home on waking up each morning. Later, she acknowledged that she was in a hospital, but did not know why she was there, and she did not understand that the other patients on the unit were also demented. She didn’t recognize hospital staff members from one day to the next. She was completely unable to remember anything that had happened recently. Nevertheless, her mem- ory for events that had happened many years earlier was quite good. Mary repeated stories about her childhood over and over again.

neurocognitive disorders CHAPTER 14 383

an expected part of the aging process. Different forms of neu- rocognitive disorder can also be confused with one another. Recognition of these disorders and the distinctions among them carries important treatment implications for patients and their families.

Delirium The DSM-5 criteria for delirium are listed in “DSM-5: Delirium.” The primary symptom of delirium is clouding of consciousness in association with a reduced ability to maintain and shift attention. The disturbance in consciousness might also be described as a reduction in the clarity of a person’s aware- ness of his or her surroundings. Memory deficits may occur in association with impaired consciousness and may be the direct result of attention problems. The person’s thinking appears disorganized, and he or she may speak in a rambling, incoher- ent fashion. Fleeting perceptual disturbances, including visual hallucinations, are also common in delirious patients (Gofton, 2011).

The symptoms of delirium follow a rapid onset—from a few hours to several days—and typically fluctuate throughout the day. The person may alternate between extreme confusion and periods in which he or she is more rational and clear- headed. Symptoms are usually worse at night. The sleep/wake cycle is often disturbed. Daytime drowsiness and lapses in con- centration are often followed by agitation and hyperactivity at night. If the condition is allowed to progress, the person’s senses may become dulled, and he or she may eventually lapse into a coma. The delirious person is also likely to be disoriented with relation to time (“What day, month, or season is it?”) or place (“Where are we? What is the name of this place?”). However, identity confusion (“What is your name?”) is rare.

It isn’t always easy to recognize the difference between de- mentia and delirium, especially when they appear simultaneously

Nurses on the unit were bombarded continuously with her complaints about being removed from her home. Every 20 min- utes or so, Mary would approach the nurses’ station, waving her cane and shouting, “Nurse, I need to go home. I have to get out of here. I have to go home and take care of my dog.” The hospital staff would explain to her that she would have to stay at the hospital, at least for a while longer, and that her dog had died several months earlier. This news would usually provoke sadness, but she seemed unable to remember it long enough to complete the grieving process. Several minutes later, the whole scene would be repeated. Mary also became paranoid, claiming to anyone who would listen that people were trying to steal her things. The most common focus of her concern was her purse. If it was out of her sight, she would announce loudly that someone had stolen it.

In the midst of these obvious problems, Mary retained many other intellectual abilities. She was a well-educated and intel- ligent woman. Her attention span was reduced, but she was still able to play the piano—pieces that she had practiced over and over again for many years. Poetry had always been one of her special interests, and she was still able to recite some of her favorite poems beautifully from memory. In a quiet room, it was often possible to talk with her and pursue a meaningful conversation. Unfortunately, these lucid periods were inter- spersed with times of restless pacing and shouting. Her agitation would escalate rapidly unless staff members distracted her, tak- ing her to a quiet room, talking to her, and getting her to read or recite something out loud.

Symptoms The symptoms of neurocognitive disorders are often overlooked in elderly patients. It can be difficult to distinguish the onset of dementia from patterns of modest memory decline that are

criteria for Delirium

A. A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).

B. The disturbance develops over a short period of time (usu- ally hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.

C. An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).

D. The disturbances in Criteria A and C are not better ex- plained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.

E. There is evidence from the history, physical examina- tion, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

DSM-5